For a year, until about six months ago, Madam Ang (not her real name), 45, put up with severe intermittent pain in her left cheek and jaw.
She would have pain attacks on the same spots that came on like an electric shock every hour, lasting for about five minutes each time. The pain worsened when she touched her face, brushed her teeth, chewed on her food or talked.
Madam Ang suffers from a condition called trigeminal neuralgia, which occurs when the trigeminal nerve - responsible for facial sensations - is affected or injured.
This debilitating condition is one of the most common causes of facial pain and affects about one in 200,000 people worldwide.
Every year, we see just over 50 new cases at the Singapore General Hospital (SGH) Pain Management Centre.
Like Madam Ang, people with this condition experience excruciating pain that affects their sleep and work. The pain can be so intolerable that they become depressed and entertain thoughts of suicide.
Facial pain can be due to diseased teeth or gums, the burning mouth syndrome where patients feel a recurring burning sensation in the mouth or postherpetic neuralgia where a facial nerve is affected after a shingles attack.
Other possible causes of facial pain are a brain tumour or a neurological condition known as multiple sclerosis.
Madam Ang initially thought she had a toothache. But the pain persisted even after a detailed dental examination found that nothing was wrong.
Painkillers did not help and the dentists subsequently referred her to SGH's Pain Management Centre.
When I first saw her at the centre, I could not examine her face as she felt pain even when lightly touched. She had lost a lot of weight as eating made the pain worse.
She also slept poorly and was depressed. Worse, she had to quit her sales job because she could not speak for long without experiencing terrible pain. Her facial pain adversely affected her livelihood and quality of life.
We sent her for a magnetic resonance imaging (MRI) scan.
The scans for about 30 per cent of the patients with facial pain show a blood vessel compressing the trigeminal nerve. For the remaining 70 per cent, the cause of the pain is usually unknown, as the MRI scan results would be normal.
Although Madam Ang's MRI scan was normal, the symptoms she was experiencing pointed to trigeminal neuralgia.
I discussed with her the possible treatment options. Most patients are usually treated with an anticonvulsant medication such as carbamazepine.
However, some patients may be allergic to carbamazepine and they would usually need to take a blood test to check if the medication is suitable for them.
Otherwise, doctors may consider other anticonvulsants or antidepressants.
As Madam Ang showed signs of depression, she was also referred to a psychiatrist and a psychologist for counselling and stress management.
Research has shown that when patients are stressed or anxious, pain therapy may not be effective.
Instead, an approach that includes medicine to treat the biological causes, psychotherapy to address the emotional aspect as well as lifestyle and social environment changes, is usually adopted when managing patients with pain.
Acupuncture to complement Madam Ang's care plan was also recommended as studies have shown that patients with this condition can benefit from a combination of both treatments.
Since 2003, the World Health Organisation has recognised acupuncture as a useful treatment for certain conditions, including pain syndromes such as trigeminal neuralgia.
In our experience, too, combining medication with acupuncture improves the treatment outcome for trigeminal neuralgia.
Fortunately, Madam Ang's condition improved after such combination treatment.
Had these conservative treatments not worked, invasive or surgical treatment would have been considered.
If the trigeminal nerve is compressed by a blood vessel, an operation to separate the nerves will be done. If there is no nerve compression, microsurgery to remove the trigeminal nerve can be considered.
A small number of patients with facial pain develop weakness in the jaw muscle, with less than 1 per cent experiencing a slight burning sensation after the procedure.
The success rate of surgery is about 98 per cent, although the pain recurs after a year in 20 per cent of patients.
When I saw Madam Ang a month after her treatment, her pain was less severe and she had fewer episodes of stabbing pain.
After six months of the combination treatment, together with psychotherapy sessions, her facial pain lessened considerably, to the point that she was able to return to work as an administrative assistant. She was also happier and able to eat more and sleep better at night.
We then lowered her medication doses and she now needs to see me just once a year for a review of her condition.
• Dr Diana Chan is a consultant at the department of pain medicine at the Singapore General Hospital.
Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.
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