Let’s talk about the first steps you need to take now that you believe your child may have Trigeminal Neuralgia. Thank you to Stacie for developing the initial list on this! I’ve added and augmented to create this post.
- Start keeping a Pain Journal
There is an entire post dedicated to this, so I won’t go into a whole lot of detail here. However, it is important to get started on this. The details of how and when the pain starts, the details of how it feels during, whether it’s constant or your child gets “attacks”, if the pain is over the eye, in the eye, in front of the ear or in the ear, etc. will be very important to a good diagnostician. Grab any notebook, or the downloadable pain journal sheets we have posted, and start tracking the details of your child’s pain.
- See a Pediatric Neurologist
This is very possibly who diagnosed your child, but if not, this is where to start. A neurologist is the one who should really go through your child’s symptoms and determine that it is in fact Trigeminal Neuralgia. S/he should also do a full neurological evaluation to be sure there are not other symptoms that should be discussed. These tests are, for the most part, noninvasive and include a lot of “does this feel the same as this” and “walk this way” and “stand on one foot” kinds of things.
Your Pediatric Neurologist can be your best friend. If you can successfully partner together and maintain regular, clear communication the two of you can determine the best medication(s) to manage your child’s pain.
That being said… Pediatric Neurologists are not trained the same as Adult Neurologists. I don’t mean this s a criticism, it’s just a reality that needs to be recognized when you are dealing with an “adult” condition. They have almost never had the need to be well versed in conditions that are rare in the first place, and also considered by text books to be an “over age 50” affliction. If you think about it, it wouldn’t make a whole lot of sense logically for them to spend all their time keeping up on conditions they will encounter so rarely, if at all.
You may think it would be better to just go to a regular adult neurologist, and you may be right. However, in our experience it is very, very difficult, if not impossible, to find an adult neurologist who is willing to take on a pediatric patient. So, in reality, we find the best situations are where parent and pediatric neurologist are working together to actively understand their child/patient’s situation, and find the best options for treatment.
- Get the right MRI.
It is very likely that one of the first things your Peds Neuro is going to want to do once they determine your child’s pain seems like Trigeminal Neuralgia is an MRI. This will look at the overall brain health and rule out certain possible causes of TN, such as tumor pressing on the nerve. Trigeminal Neuralgia is also a symptom, and sometimes an early symptom of Multiple Sclerosis. An MRI cannot definitively determine MS, but can give an indication of whether further investigation in this direction is warranted.
However, we have run into a number of cases – including among us! – where the wrong, or at least not the best, MRI is ordered. Following is a quote from our neurosurgeon in the MRI to get:
“Every center calls it a different name. It also varies according to machine manufacturer. At UCI we call it a ‘with & without contrast cranial nerve protocol MR’. It includes general FLAIR & T2 non contrast scans to rule out Multiple Sclerosis. It includes SPGR contrast tri-planar thin cut (1mm) and magnified posterior fossa images. Most importantly it included T2 volumetric acquisitions with 0.8mm slice thickness in all three planes. Depending on the machine manufacturer, these latter series can go by the name of CISS or FIESTA. This last series in my opinion is the most important and informative for identifying vascular contact.“
We will have another post on MRI results and the complicated discussion that can be. For now, let’s leave it here.
- Start on anti-seizure medications.
The first line of attack as far as medication goes for Trigeminal Neuralgia are anti-seizure medications, the same meds that are given to epilepsy patients. These have been found to be most effective for those suffering from classic Trigeminal Neuralgia. These medications include:
- Tegretol (Carbemazepine)
- Trileptal (Oxcarbazepine)– a “brother” of Tegretol shown to have fewer side effects for many
- Aptiom/Zebinix/Exalief (Eslicarbazepine) – the most recent derivation of Tegretol, hopefully even better than Trileptal when it comes to side effects.
- Gabapentin (Neurontin) – while the above work to stop the Trigeminal Nerve from being triggered in the first place, Gabapentin works to shut down a trigger if it does occur. For this reason, Gabapentin is often used in combination with one of the above, if the pain is not as well managed with just the one medication.
One of these medications may be prescribed on the first visit to the neurologist, even before the MRI is ordered. (However, we would recommend asking for both the prescription and the order for the MRI as soon as “Trigeminal Neuralgia” is on the table.) Having the pain respond well to these medications is often used a s diagnostic indicator for TN: if several days after beginning the medication your child’s pain is measurably reduced, it is further proof you really are dealing with Trigeminal Neuralgia. However, there is a lot of variation in response to medications, so not responding doesn’t necessarily mean you are not dealing with Trigeminal Neuralgia.
An important note on these medications: These medications are made to work when being consistently taken, and take 3 to 5 days to build up in the body and effective at the dosage. Therefore, you need to take them on a regular schedule, and not expect for them to start helping for several days. This also means that taking a dose at the onset of pain will not help that pain. (There is a fast-acting Tegretol pill, and that is a different situation.) It also means if the pain goes away, the medication is working and you should stay on it, unless your doctor is in agreement on attempting to wean off or to a lower dosage. Weaning off should be done carefully, and under a doctor’s supervision as the sudden stopping of them can actually cause seizures and other nasty effects.
Also, again just from our experience and WE ARE NOT MEDICAL PROFESSIONALS, we have found that not throwing a number of different medications at this at one time is very helpful in determining what is actually working and not. Plus, the drug interactions start stacking up and it can quickly get very complicated when you just need an over the counter cough medicine one day. Over time these kids may wind up needing drug cocktails of multiple medications, but the slower the progression of that, the easier your life will be.
Note on Steroids: It is not unusual for a short dose steroid pack to be recommended. Trigeminal Neuralgia, while not at its root caused by inflammation, can be aggravated by inflammation of the nerve due to some other health issue. Some kids find that an “increased flare time” can be helped somewhat by a short-term steroid, if some form of inflammation of the nerve is causing their pain to spike or occur more frequently. Even post-surgery several of our kids had their TN pain kick up, only to find later they were fighting a cold, bronchitis, or ear infection that also happened to inflame their damaged/healing nerve. The steroids may be worth a shot.
We will say more about life on these meds in another post.
- Keep your child’s overall health and immunity functioning well.
As our neurosurgeon has explained to us, damaged nerves can be affected by Sickness, Stress, and Sleepiness. Therefore, it is our goal to minimize those things in our children to avoid making a tough situation even worse. This means doing those “healthy lifestyle” things that were always good suggestions before, but maybe allowed to let slide more than you want to now. So keep in mind things like:
A solid 8 hours of sleep a night. Or more. Pain, medications, and the upheaval your child is going through right now take a toll, so 8 hours is a guideline. In our (Megs) house, we made sure our girl got to sleep at a reasonable hour, and let her naturally wake up in the morning. I realize not everyone’s life allows for that, but seriously look at your schedule and make sure enough sleep is gotten at night. Also, the medications, especially at first, tend to really cause exhaustion. So don’t be surprised if LONG nights sleep and naps are needed.
Nutrition is important. On high pain days we would often allow treats and not be strict at meal time. And that’s totally understandable. When your child just spent hours in intense pain, how do you say no to chocolate dessert? However, overall, really try to keep them on a balanced diet with good vitamin-rich foods, and add a multi-vitamin if they are not on one already. Their bodies are carrying them through a lot and need the strength to do so.
Avoid exposure to communicable sickness. A bit of a cold can really amp up their pain because of the aforementioned inflammation issues, and complicate their TN in ways you won’t anticipate. Our girl had the worst time with a congested cold because breathing over her teeth was triggering her pain, but she couldn’t breathe through her nose. While your child still has to have a life, and still has to see friends and enjoy themselves whenever they can (that’s a topic for another post!), be conscious of the ramifications of those decisions and use wisdom.
Avoid excessive stress. I hate even listing this one, because we all know if you are wrestling TN, stress has moved right into your house and camped out in the living room. However, just keep this is mind. An overload of stress can cause damaged nerves to fire up, causing pain. So whatever helps your child with stress relief, try to build it in to life. A little exercise if s/he is up to it? Curling up on the couch and watching a movie with you? A good back rub some time? Listening to their favorite music? If you notice a higher level of stress coming from them, try to learn their stress relief needs and suggest it.
You may think it’s going to be really hard to get your child to go along with these things, and I’m sure there will be days it’s a real pain. We found though, that when we framed the issue with minimizing TN attacks and pain, we had a far greater cooperation.
- Try a variety of pain management techniques.
There are probably as many strategies for dealing with the pain as there are TN patients, so experiment. It is pretty common for TN patients to want darkness and quiet. Often they can’t stand to be touched. Other possibilities are movement, vocalizing (otherwise known as moaning/yelling), heat or cold packs, etc. At some point we will dedicate a post to a master list of things to try.
In the meantime talk to your child some time when they are not in pain about their ideas and be prepared to try it when needed. We slowly built a standard assortment of things she wanted with her during pain. Her favorite stuffed animal. Her own pillow. Super-soft blanket. Box of tissues. Pain journal & pen (for mom). Moms cell phone in case we need to text/call doctor. We literally hauled these things wherever we went – which was mostly doctor’s appointments – during the bad times.
Hopefully this will help you get started as well as you can.
Hugs to you.