Facial pain is a typical daily experience by nearly one-quarter of Americans. There are so many causes and so many facial pain types, such as Postherpetic neuralgia (shingles), trigeminal neuropathy, TMJ pain, cluster headaches, and Trigeminal Neuralgia.
Trigeminal Neuralgia is also medically referred to as tic douloureux and commonly known as the Suicide disease.
Itis a rare disease compared to other causes of facial pain, and because of this characteristic excruciating pain, people tend to get thoughts and even confess suicide tendencies.
The condition is a very painful disorder affecting the trigeminal nerve, which is the nerve that transfers the sense of pain and touch from the face and the eye to the brain. In suicide disease, two to four branches of the trigeminal nerve are affected.
Suicide disease is a form of neuropathic pain. There are two major categories of suicide disease: typical trigeminal neuralgia and atypical trigeminal neuralgia.
The former (typical trigeminal neuralgia) is a form that results in episodes of sudden, shock-like, severe pains on one part of the face that may last for few seconds.
In this type of suicide disease, a group of these episodes can occur over a few hours. The atypical form, on the other hand, results in a constant burning pain that is less severe.
Both forms of suicide disease can occur in the same person. Painful sensations can be presents either lateral or bilateral. And episodes may be triggered by a slight touch to the face.
Suicide disease is one of the most painful conditions known to man and medicine but surprisingly remains mysterious to many clinicians and professionals.
Suicide disease (Trigeminal neuralgia) was described by physician John Fothergill for the first time, and the condition was first surgically treated by John Murray Carnochan; both gentlemen were graduates of the University of Edinburgh Medical School.
The name “suicide disease” was first coined from the studies by Harvey Cushing that involved 123 cases of Trigeminal Neuralgia during 1896 and 1912. The condition has reported an annual incidence of 4.3 per 100,000 persons, with a slight predominance to the female generation.
The peak incidence is at 60-70 years of age, and classical trigeminal neuralgia is unusual before age 40.
Suicide disease is of nerve pain, and it has other names such as Prospalgia, Fothergill’s disease, and Tic douloureux.
The condition is said to have an unknown cause, but some clinicians believed the etiology of suicide disease to involve loss of the myelin of the trigeminal nerve or any of its branches (ophthalmic, maxillary, and mandibular nerves).
A mixed cranial nerve that relates sensory data of pressure, temperature, and pain originating from the face above the jawline is the Trigeminal nerve.
This nerve is also responsible for the motor function of the muscles involved in chewing but not the facial expression (the muscles of mastication).
The loss of myelin is suspected to be due to compression from the blood vessels as the nerve comes out from the brain stem, most commonly the superior cerebellar artery, compressing against the microvasculature of the trigeminal nerve close to its connection with the pons.
Such a compression can result in an injury of the myelin sheath protecting the nerve (demyelination) and cause erratic and hyperactive dysfunction of the nerve.
This dysfunction is the cause of pain attacks at the slightest stimulation of the area served by the nerve and also the cause of hindrance of the nerve ability to shut off the pain signals after the stimulation ends.
Demyelination is hardly due to an aneurysm (an outpouching of a blood vessel), stroke, multiple sclerosis, or trauma. Less frequently discovered causes of suicide disease include tumor or arteriovenous malformation.
Suicide disease is found in 3-4% of patients with multiple sclerosis, theorized to be due to damage to the spinal trigeminal complex. Trigeminal pain has a similar presentation in people with and without multiple sclerosis.
Symptoms of Suicide Disease
One of the major indicators of suicide disease is acute pain on one or both sides of the face that typically lasts for seconds.
The pain is so immense that it can create suicidal tendencies in patients, usually occurring around the eye, lips, cheeks, and lower part of the face.
Pain may be triggered by:
- Shaving, washing, or wind
- Touching, talking, or rubbing the face
- Brushing of teeth or hair
- Chewing, drinking, or eating
- Kissing and involuntary facial expressions, such as yawning and smiling.
Diagnosis of Suicide Disease
The diagnosis of suicide disease is based on the medical history of the patient, after analysis of symptoms presented by the patient, and description of pain.
Magnetic resonance imaging (MRI) is also very useful in confirmation diagnosis and differential diagnosis. In most cases, blood vessels can be seen pressing against the trigeminal nerve.
Some other conditions that are included as a differential diagnosis after a careful examination may disclose local findings indicative of otitis, sinusitis, or dental disorders.
The conditions present a history of persistent pain lasting longer than two minutes.
Some of these conditions include:
- Giant cell arteritis: Persistent pain and bilateral jaw claudication
- Glossopharyngeal neuralgia: Pain in tongue, mouth, or throat, brought on by swallowing, talking, or chewing.
- Dental pain (caries, cracked tooth, pulpitis): Localized pain related to biting or hot or cold foods, visible abnormalities on oral examination.
- Cluster headache: Longer-lasting pain (orbital or supraorbital); may cause the patient to wake from sleep, autonomic symptoms.
- Intracranial tumors: May have other neurologic symptoms.
- Migraine: Longer-lasting Pain closely associated with photophobia.
- Otitis media: localized ear pain, visible abnormalities on examination, and tympanogram.
- Multiple Sclerosis: Eye symptoms and other neurologic symptoms.
- Trigeminal neuropathy: Persistent pain associated with sensory loss.
- Temporomandibular joint syndrome: Persistent pain, localized tenderness, and jaw abnormalities.
- Postherpetic neuralgia
- Paroxysmal hemicranias
- SUNCT (Shorter lasting, Unilateral, Neuralgiform, Conjunctival injection, and Tearing).
Treatment of Suicide Disease
Suicide disease is treatable and different definitions of treatment interventions, whether medical or surgical, have been recorded.
If half of the pain subsides compared to baseline readings occur with pharmacological therapy, it is considered a success. However, with surgical studies, measurements are different.
Complete pain relief is one of the major aims of treatment of Suicide disease. The anticonvulsant carbamazepine is the first medication line of treatment; the second line of medications includes lamotrigine, baclofen, oxcarbazepine, phenytoin, pregabalin, and gabapentin.
Antidepressant medications like amitriptyline have shown good efficacy in treating trigeminal neuralgia, especially when combined with an anticonvulsant drug such as pregabalin.
Duloxetine, with some evidence, has been shown to be an effective treatment for neuropathic pain, especially in patients with a major depressive disorder, as it is an antidepressant. But it should by no means be considered the first line of medication therapy and should only be tried on specialist advice.
Surgically, microvascular decompression provides freedom from pain in about 70% of cases present drug-resistant trigeminal neuralgia.
In almost all cases, there is a relief from the pain after surgery, but there is also a risk of pain relapse, adverse effects such as facial numbness, and permanent nerve damage.
Surgical procedures for Suicide disease are divided into non-destructive and destructive.
- Microvascular decompression
This involves making a small incision behind the ear and removing some bones from that location. A cut through the meninges is made to reveal the nerve, and any vascular compressions on the nerve are carefully shifted, and a sponge-like pad is placed between the vascular compression and the nerve.
The pad stops unwanted pulsation and allows the myelin sheath to heal.
All surgical procedures under this group will cause facial numbness, post relief, as well as pain relief. They include:
- Balloon compression-inflation of a balloon at the nerve point causing damage and stopping pain signals.
- Glycerol injection- deposition of a corrosive liquid called glycerol at the nerve point that causes damage to the nerve to hinder pain signals.
- Radiofrequency thermo-coagulation rhizotomy- application of a heated needle to damage the nerve at this point.
- Stereotactic radiosurgery- a form of radiation therapy that focuses high-power energy on a small area of the body.
- Percutaneous techniques
Complication on Suicide Disease
Some complications that may arise in the course of suicide disease (trigeminal neuralgia) treatments or management are:
- Lack of relief and recurrence of neuralgia are the primary risks with suicide disease treatment.
- Abnormal facial sensation (facial dysesthesia)
- Facial numbness
- New facial pain
- Corneal anesthesia
- Weakness in jaw muscles (masseter weakness)
Microvascular decompression has additional risks that include:
- Anesthetic side effects such as headache, confusion, and Nausea.
- Surgical risk such as Hemorrhage, blood clots, injury to the brain stem, injury to the cerebellum, infection, and cerebrospinal fluid leakage.
Social and psychological support has been found to play a major role in the management of chronic illnesses and pain conditions, such as suicide disease.
Chronic pain can frustrate an individual as well as those around them. As a result, there are many advocating groups that can aid a person’s cope with the condition.
Some famous case of suicide disease that has presented substantial evidence and served as references include:
- Salman Khan, the Indian Bollywood film star, was diagnosed with suicide disease in 2011. He underwent surgery in the US. He shared that at one point, he felt suicidal, although he channeled his energies and worked harder. He said, “That’s one disease that basically has the highest rates of suicides…There is so much pain…I suffered that…”
- Minister William Gladstone, Four-time British Prime, is believed to have had the disease.
- Author Melissa Seymour was diagnosed with suicide disease in 2009 and underwent microvascular decompression surgery in a well-documented case covered by newspapers and magazines to help create an awareness of the disease.
- Christy Toye, All-Ireland-winning Gaelic footballer, was diagnosed with suicide disease in 2013. The footballer spent all five months in his bedroom at home and returned for the season in 2014 and lined out in another All-Ireland final with his team.
- In 2004, Afrikaans singer and songwriter, popular during the 1990s, Anneli van Rooyen was diagnosed with atypical trigeminal neuralgia. During surgical therapy in 2007, a surgery directed at alleviating her condition went wrong, and the superstar suffered permanent nerve damage, which leads to her complete retirement from performing.
- British author, human rights campaigner, magistrate, founder, and president of Freedom Charity, Aneeta Prem, began experiencing bilateral Trigeminal neuralgia in 2010, with severe pain and resulting sleep deprivation. Her condition remained undiagnosed until seven years later, and MVD surgery to reduce the pain on the right-hand side was conducted at UCHL in December 2019.
- Drummer of Rock band Blink, Travis Barker also suffered from a case of Suicide disease.
- Trigeminal Neuralgia; https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/syc-20353344
- Trigeminal Neuralgia; https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Trigeminal-Neuralgia
- Trigeminal neuralgia; https://www.nhs.uk/conditions/trigeminal-neuralgia/
- Trigeminal Neuralgia; https://www.healthline.com/health/trigeminal-neuralgia