Archive for July 2017

Painful Spasms of the Face

As I sat in the midst of a group of folks pleasantly chatting at a friend’s surprise birthday party, I couldn’t help noticing the grimaces of a woman across from me.  Every minute or two she would wince as though being jabbed with a needle.  When I asked about this privately she filled me in.  “Since this morning it feels like every couple of minutes or so I get a really sharp, excruciating stab of pain near my left ear.  It lasts just a couple of seconds but they’re so frequent its wearing me out.”

This lady was describing a somewhat uncommon, but extremely painful condition called trigeminal neuralgia (TN), or less commonly, tic douloureux (which just means “painful spasm”).

TN is a jolting jab of pain along one of the five branches of the trigeminal nerve.  The trigeminal nerve is the main nerve of sensation for the face and part of the scalp.  Most of the time the cause of the nerve malfunction is unknown and there is no simple blood test or imaging study to diagnose this.  But the symptom is quite characteristic and usually makes the diagnosis clear.

TN has been described for well over 300 years and surgical treatments for it began over a century ago.  In fact a first century Greek physician, Aretaeus of Cappadocia is thought to have been referring to TN when he described a headache in which “spasms and distortions of the countenance took place.”

The frequency of TN is only about 1.5 cases per 10,000 people per year.  It occurs primarily in the middle-aged to elderly population, rarely occurring before age 40.  The relative rarity of TN is a good thing as it can become so severe in some cases that, if not treated, it has pushed patients to the brink of suicide.  The agonizing jabs of pain can occur anywhere from once every couple of days to hundreds of times per day.  Most commonly they shoot from the corner of the mouth to the angle of the jaw.  But they can also shoot from the area around the upper canine teeth toward the eyebrow.

So, what can be done about this agonizing malady if it strikes?  Fortunately, there are some fairly effective treatments.  For starters, certain medicines like Tegretol, gabapentin and Lyrica have shown benefit.  Other meds can be used as add-ons if needed.  These can give desperately needed relief.  The course of TN is quite variable.  So sometimes, if one of these meds can help in the short run, the pains dissipate over a few months and the person can go off the meds and do well.  But in a majority of cases the pain returns at some point and it is not uncommon for the meds to begin to lose their effectiveness.

In more stubborn cases, certain surgical procedures can be effective, such as a procedure where pressure is taken off of the afflicting nerve branch.  Obviously TN is no picnic to go through.  But at least there are a few fairly effective options that weren’t around when Aretaeus observed his patient with “spasms and distortions of the countenance.”

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Feeling the Heat


I’m generally not a big sweater.  But last evening as my wife saw me returning from chipping and putting a few balls around she noticed the large wet patches on my shirt.  “Did you end up going on a bike ride or is that just from hitting a few golf balls?”   I responded that is was, “All from just strolling around and hitting a few balls.”

This is the time of year in Tennessee when any kind of outdoor physical activity during the daylight hours is majorly sweat-producing.  Indeed, sometimes the heat can really cause a problem for people.  Specifically, there are three heat-related illnesses.  The mildest one is heat cramps with symptoms including muscle cramps, fatigue, thirst, and heavy sweating.  It can usually be treated by getting to a cool place, resting, and hydrating with water, sports drinks, or other rehydration drinks containing electrolytes.

The next, more serious, heat-induced condition is heat exhaustion.  If this hits you, you may notice the symptoms of heat cramps as well as rapid pulse, feeling lightheaded, nausea, headache, and sometimes, cool moist skin with goose bumps.  If you start noticing some of these symptoms, stop all activity and rest in a cool place, and hydrate (not with alcoholic or caffeinated beverages).

If untreated, heat exhaustion can go on to heat stroke, a potentially deadly condition.  In heat stroke the body temperature reaches 104 F or higher.  The skin may be moist or, worse, hot and dry, as the heat challenge overwhelms the body’s ability to cool itself by sweating.  In addition to all the symptoms of heat exhaustion, there may be confusion, agitation, irritability, and sometimes, fainting.  Heat stroke is a medical emergency requiring immediate treatment to avoid damage to the brain and other vital organs or even death.  If you are with someone exhibiting symptoms of heat stroke, call 911 immediately as this isn’t one to just treat on your own. While waiting, move the person to a cool place and cover with a wet sheet or spray with cool water and encourage hydration if they are able to drink.  Fan them to encourage evaporation of the water on them which will further cool them.

Heat-induced illnesses are not terribly rare.  One source lists heat stroke as the third leading cause of death in American athletes.  These cases would be what is called exertional heat stroke, where physical activity is a major player in the overheating.  There is also non-exertional heat stroke which occurs in a person not physically active but overwhelmed by a very hot environment.

There are a few other factors besides the temperature, humidity, and exertion that put someone at greater risk for heat illness.  These include poor hydration, alcohol intake, overdressing (especially if the clothing doesn’t allow evaporation of sweat), very young or old age, and certain medications such as beta blockers, antihistamines, and diuretics.

Mid-summer in Tennessee is still a good time to be outside, but limit your time in the heat of the day and keep hydrating to stay a long ways from these serious heat illnesses.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835