Treatment with Saturated Fats: Lies or Legitimacy?

The pain associated with Trigeminal Neuralgia is so severe that it has been christened "the suicide disease;" because the pain can be triggered by any number of external stimuli (or even nothing at all), patients experience frequent misdiagnosis; treatments can range from noninvasive medication, to alternative acupuncture, to drastic surgeries. Given all these facts about TN, it is difficult to envision a solution as easy as altering the saturated fat in your diet. Personally, I'm not one to buy into "miracle diets," whether they simply lead to magical weight loss or the cure for cancer, and because no formal study has been conducted that links a decreased saturated fat intake to reduced neuralgia pain, I'm equally reluctant to suggest diet change as a legitimate cure for neuralgia.

However, I have to admit that the mystery and diversity of neuralgia cases- including the myriad triggers and variable responses to treatment- has made it nearly impossible to develop a unified and consistent approach to neuralgia anyway. If some patients respond as well to medication as some do to surgery, then wouldn't it be worthwhile to test a treatment that, even if it doesn't cure your condition, will only make you healthier? Reducing the saturated fat in one's diet would be a basic (and easily reversible) step to take for curing neuralgia, and it would certainly yield an enormous ROI for those who experience results.

So, to the debate: what are the effects of saturated fat on patients suffering neuralgia? Again, no direct correlation between saturated fat and nerve pain has been established, but Mayo Clinic doctors have stated that saturated fats can reduce the body's ability to repair damaged nerves. Patients at MD Junction say they can at least control their pain if they keep their intake of saturated fats below 10 grams/day. According to those who have experienced results, the pain does not decrease until 1.5-2 weeks after beginning a low-saturated fats diet.

At the Trigeminal Neuralgia Association's National Conference in 2004, Frank Sherwood (not a doctor) presented a paper on the validity of the low-saturated fat diet for TN. The paper primarily discussed the case-study of an 82-year old TN patient (the presentation can be found at http://www.franksherwood.com/mytalk.htm). The patient was diagnosed with typical TN after a root canal, and controlled the pain for seven years with medication (mainly Tegretol), one successful glycerol injection, and then nearly nine years of varied, unfulfilling treatment options. Finally, in preparation for surgery, the patient followed the American Heart Association diet, which reduces saturated fat to 20%, and her pain was dramatically reduced. Of course, the internet is full of testimonials for "miracle diets," and the one pseudo-study conducted in conjunction with Sherwood's presentation is not very conclusive (50% of 22 patients reported "substantial improvement" in a questionnaire), but even if the diet-as-treatment is not substantiated, the health benefits of consuming less saturated fat are medically supported.

Saturated fat is the main dietary cause of high blood cholesterol, according to the American Heart Association. It is found mostly in foods from animals (red meat, whole milk, cheese, butter) and plants (coconut, coconut oil, tropical oils). Also, unfortunately you would want to minimize your intake of sweets: chocolate, candy, ice cream, cakes, cookies. In general, good foods to eat are: seafood, beans, rice, pasta, vegetables, fruit, and very small amounts of lean poultry (chicken, turkey). The American Heart Association recommends limiting saturated fat intake to less than 7% of total daily calories. For example, a sedentary female age 31-50 (who should be consuming approximately 2000 calories a day) should be consuming less than 16 g saturated fat. Of course, when checking labels for saturated fat content, be sure to note the "serving size." The chocolate bar you are about to polish off could actually constitute two serving sizes, and thus contain twice the saturated fat content listed on the label.

Overall, although still not convinced by testimonials, if suffering from TN I would certainly be willing to experiment with a low-saturated fat diet for a month or two. Counting the grams of fat in my food is a small concession to make if it definitely improves my health and possibly cures my disease.

Gamma Knife Surgrey: The Best (Radical) Option?

In October 2005, ScienceDaily published an article concerning research performed at the Comprehensive Cancer Center at Wake Forest University Baptist Medical. The article, titled "Gamma Knife Effective in Treating Trigeminal Neuralgia," states that Gamma Knife Stereotactic Radiosurgery (GKRS) is a safe, effective alternative treatment for patients suffering from neuralgia. Typical side effects of surgical treatments can include facial numbness, as well as problems with infection or anesthesia because they require incisions. GKR, on the other hand, is a non-invasive procedure that relies on small beams of radiation to target the problematic nerve. ScienceDaily reports that, in the Comprehensive Cancer Center research: "Ninety percent of patients with trigeminal neuralgia had significant pain relief within an average of four weeks. Approximately one-third of these patients did experience some degree of facial numbness, but 80 percent reported a significant improvement in their quality of life since the numbness was much more tolerable than the facial pain."

Gamma-Knife Radiosurgery works by focusing 201 beams of cobalt-60 radiation on a specific region in the brain; for Trigeminal Neuralgia patients, this target area is the trigeminal nerve, at the point where it exits the brain. The treatment does not require general anesthesia, and the patient stays in the hospital for less than five hours. However, because it deals with radiation, risk of radiation injury increases with the amount of tissue receiving treatment. Radiation injury can cause latent swelling, which usually resolves itself but can also be controlled with corticosteroid medications for persistent brain swelling.

One positive aspect of GKR is that most patients are eligible for the surgery; because it is non-invasive, it is a possible treatment for the elderly, as well as patients suffering other medical conditions. However, because the treatment is so recently developed (most cases of TN have been treated within the last five years) that there is not much information on long term effects, although no major complications have been reported to date.

Overall, patients report a drastic reduction of pain (80-90%), with results similar to that of microvascular decompression and radiofrequency lesioning (the advantage to GKR, of course, is the fact that it is a non-invasive, outpatient procedure). The major disadvantage to GKR is its delayed effect: it can take 4-6 weeks for a patient to notice a difference in pain.

Anti-convulsants: Primary Treatment for TN

Today, Trigeminal Neuralgia is most frequently and effectively treated with anticonvulsant, also known as antiepileptic, drugs. One proposed cause of trigeminal neuralgia is degeneration or damage to facial nerves, causing them to compensate for "mismatched" signals by becoming hypersensitive. Anticonvulsant medications work by regulating incoming and outgoing signals in the nerves, quieting these "distress" signals and the accompanying pain felt by TN patients. Although prescribed less frequently, anticonvulsants may also be used to treat postherpetic neuralgia.

The greatest obstacle to anticonvulsant drugs as treatment for TN is their side effects; these include dizziness, confusion, drowsiness, double vision, nystagmus (eye twitching) and nausea, as well as dramatic changes in blood levels. Anticonvulsants have also been linked to an increased risk of suicidal tendencies, so if you are taking anticonvulsants (especially for the first time), you should be extra aware of any changes in behavior or thought, and notify your doctor immediately. Carbamazepine, the chief anticonvulsant for treating TN, can also trigger a serious reaction is some people (most commonly those of Asian descent). Normally, initial treatment with anticonvulsants involves only one medication, but many patients end up requiring a combination of drugs, or higher dosage if the medications begin to lose effectiveness.

Carbamazepine is, in most cases, the most effective (and most prescribed) drug for treating TN. It is so effective that relief from pain with carbamazepine is often a good indicator that a patient does indeed have TN. Nearly all patients prescribed carbamazepine- usually in the form of Tegretol- complain of side effects, although these fade as the body adjusts to the medication (which, unfortunately, can last as long as the time it takes to increase dosage). More potentially serious side effects that have been linked with carbamazepine that are not dose-related are memory loss, skin rash, and blood problems (found in 2-6% of carbamazepine users). These blood problems include a drop in the number of white blood cells, hyponatremia (low sodium in the blood), and aplastic anemia (the bone marrow stops making blood cells). Oxycarbamazepine (Trileptal) is a new form of Tegretol that may involve fewer side effects, but must be taken in higher doses. Additionally, Gabapentin has fewer side effects than carbamazepine, but is almost as equally effective.

Other alternative medications for carbamazepine include:
Phenytoin (Dilantin, Phenytek)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Levateracitam (Keppra)
Pregabalin (Lyrica)
Topirimate (Topamax)
Valproic acid (Depakote)
Clonazepam (Klonopin,Rivatril)

Generally, the above medications are less effective than carbamazepine, and the differences among them are more arbitrary. However, they do have less severe side effects and can be used in combination with each other to strengthen their pain reduction.

PHN Treatment: Antidepressants

To treat neuralgia, specifically trigeminal and postherpetic neuralgia, physicians typically begin by prescribing antidepressants, anti-convulsants, or anti-spasticity drugs. Normally, antidepressants function by regulating levels of serotonin, dopamine, and norepinephrine in the brain to increase the sensitivity of nerve cells to glutamate, which is a non-essential amino acid linked to anxiety and depression, as well as the way one's body interprets pain; however, these medications are usually prescribed in smaller doses for neuralgia patients. Specifically, tricyclic antidepressants (which also affect nervous sodium channels) are usually prescribed to patients suffering from postherpetic neuralgia (PHN), rather than trigeminal or glossopharyngeal neuralgia.

These antidepressants should ease nerve pain within a few days, although they can also take up to several weeks to begin working fully, and are less effective in patients with burning pain or pain triggered by external stimuli. They are more effective when started within the first year after symptoms occur. Patients usually become dissatisfied with medication therapy, because it only moderates the pain and nerve pain can re-emerge unless dosage is increased over time (this is actually a phenomenon that has developed among patients suffering depression; no scientific correlation to neuralgia patients has been established). Side effects for tricyclic antidepressants include: dry mouth, constipation, bladder problems (especially in men with enlarged prostrate conditions), impaired sexual function, dizziness, drowsiness, blurred vision, increased heart rate, and weight gain. Unfortunately, side effects are more severe in the elderly- who are more at risk for neuralgia.

Nortriptyline (Pamelor, Aventyl), amitriptyline (Elavil, Endep), and desipramine (Norpramin) are standard drugs, but desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. In a study published in 2005 by the UCSF Pain Clinical Research Center, Michael Rowbotham treated postherpetic neuralgia patients with desipramine, amitriptyline, and fluoxetine. He concluded that: "Desipramine produced the greatest reduction in pain intensity (47%), followed by amitriptyline (38%) and fluoxetine" (Journal of Pain, Vol. 6, Issue 11). Additionally, he found that fluoxetine exhibited the most severe side effects: "The fluoxetine group had the highest noncompletion rate, with 1 subject hospitalized for hyponatremia. Although the magnitude of pain reduction and the category pain relief rating was not significantly different among the 3 drugs, the tricyclics desipramine and amitriptyline were well tolerated and provided clinically meaningful pain relief in 53% to 80% of subjects."


Antidepressants for neuralgia include:

- Amitriptyline: Elavil, Amitril, Emitrip, Endep, Etrafon, Levate, Limbitrol, Novotriptyn, Triavil. This is the most commonly used antidepressant for neuralgia treatment, and in most cases it does NOT demonstrate a loss of affectivity over time.

- Protriptyline: Vivactil

- Nortriptyline: Aventyl, Pamelor

- Desipramine: Norpramin

- Duloxetine: Cymbalta

- Fluoxetine: Prozac (US), Seronil, Fontex (Europe). The use of fluoxetine to treat neuralgia is more experimental, and often used only as an alternative to oter antidepressants, due to its higher cost.

Diagnosing Neuralgia

Neuralgia presents a conundrum to both doctors and patients, because of the difficulty inherent in diagnosing it. Although there are common symptoms for neuralgia, such as a constant, burning pain or a short, stabbing pain (both in localized areas), these are also symptoms which accompany a variety of other disorders. For example, people with trigeminal neuralgia are often diagnosed with having toothaches or even damage to the jawbone. This can be further complicated by the irregularity of the pain attacks; remission can last for months and typically there is no lasting paralysis, although episodes are sometimes precluded by a more lasting, throbbing sensation. In extremely rare cases, localized numbness and muscle spasms accompany the pain, which can be severe enough to also disrupt regular heartbeat rhythms.
Also involved in diagnosing neuralgia is pinpointing the nerve from which the pain is originating; unfortunately, this is difficult to do, and oftentimes the origin of the pain remains unknown. The mechanisms in the nervous system that are often actually attributed to neuralgia include: overly-sensitive neural receptors, malfunctions in the ion-transfer process along neural pathways, cross-signaling between large and small fibers, or damage in the central nervous system that "misreads" peripheral signals.

Introduction to Neuralgia

Neuralgia is characterized by a burning or stabbing pain that follows the path of a nerve. Because it usually occurs in conjunction with nerve damage or degeneration, it is most common in people over the age of 50 (and is more often diagnosed in women than men). Typically, it is classified by the type of nerve involved, the most common diagnosis being "trigeminal neuralgia," which involves intense pain on one side of the face. Although it can be a result of nerve damage or inflammation, the most common cause of trigeminal neuralgia is nerve compression (pressure- in this case from facial blood vessels- that inhibits normal neural pathways). Neuralgia can be a difficult condition to live with, not only due to the debilitating pain, but also because it can be triggered by the slightest external stimuli: such actions as brushing one's teeth or walking in a cool breeze can prompt intermittent bouts of stabbing pain that lasts anywhere from a few seconds to a few minutes at a time; sometimes, such episodes can be precluded by a prolonged throbbing sensation.
The easiest form of neuralgia to diagnose is postherpetic neuralgia, which exists in regions of shingles outbreak. Shingles (herpes zoster) arises when dormant chickenpox virus in nerve cells reactivates, causing pain, rash, and blisters. Although the skin usually heals within a month, sometimes pain persists and this is postherpetic neuralgia.
Two other recognized forms of neuralgia include occipital neuralgia and glossopharyngeal neuralgia. The first is pain in the neck, back of the head, or behind the ears resulting from damage, inflammation, or compression to the occipital nerves in the head. The latter, most rare form of neuralgia, is actually more common in men, and involves pain in the tonsils, tongue, or the back of the throat. Similar to the other cases of neuralgia, it is assumed that the pain results from compression of, or damage to, the glossopharyngeal nerve, although the exact cause is unknown.