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Trigeminal Neuralgia

“I keep getting this sharp stabbing pain from the corner of my mouth to the angle of my jaw.  It feels almost like a jabbing electric shock and it’s excruciating.  After that it starts getting better slowly over a few minutes.  But I keep wondering when the next one’s going to hit.”

My middle-aged patient 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.  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.”

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Cholesterol Myths

“So, my cholesterol’s running high?  It’s probably all those eggs I’m eating.  Give me a couple of months and I can fix that with my diet.  I don’t want a heart attack… but I also don’t want to be on one of those statin drugs.  Who wants something that saves your heart but then wrecks your liver?

Those are the kinds of statements I hear day in and day out in my practice.  They express several of the myths that are rampant about cholesterol.  In fact cholesterol has recently been in the news because the government’s Dietary Guidelines Advisory Committee is reportedly going to remove their longstanding recommendation to restrict cholesterol in the diet.

The wheels of science often grind very slowly and sometimes get stuck in a misguided rut for long stretches.  One of those ruts has been the idea that cholesterol in the diet, such as is contained in the yolk of an egg, needs to be carefully limited in order to protect one’s heart health.  It seemed to make sense since cholesterol is found in some of the plaque that blocks arteries and leads to heart attack and stroke.  But over the years the evidence for the evils of dietary cholesterol has simply not shown up.  In fact, as heretical as this may at first sound, a lot of folks with the very common pre-diabetic metabolic syndrome would do better having an egg and a little cheese for breakfast rather than a bowl of oatmeal.

Even after decades of study, we are far from figuring out all that there is to know about cholesterol and cardiovascular health.  But if we can’t give all the answers, let’s at least explode a few myths.  Besides the one noted above about the assumed dangers of dietary cholesterol, here are three more:

  • Myth #1: High cholesterol is mostly due to a bad diet and can be readily fixed by adjusting your diet.  Reality: For most people cholesterol is about 80% genetics and 20% lifestyle.  So it can certainly be improved with a healthy lifestyle, but there is a large part of it over which we have little control.  It’s still good to work at the 20%, but it’s not a simple fix.
  • Myth #2: Anyone with high cholesterol is at risk and would probably benefit from a statin drug.  Reality: These cholesterol-lowering medicines do work very well to lower cholesterol.  However, the main place that they have shown a reduction in events (such as heart attacks) is in folks with known heart disease, or (less so) in those with very high risk factors for heart disease.  Some folks with high cholesterol are actually at very low risk for heart disease and stroke.  That’s why in trying to better answer whether one of our high cholesterol patients should consider a statin, we employ tests such as the coronary calcium scores and/or a specialized arterial ultrasound called a carotid intimal medial thickness test.  These are non-invasive and affordable tests which help us sort our high cholesterol patients into those who are clearly plaque-formers and those who don’t seem to be.  We then recommend consideration of a statin, as well as other aggressive preventive measures only for the plaque-formers.
  • Myth #3: Cholesterol-lowering statin drugs are quite dangerous and can wreck your liver. Reality: Although, as noted above, they are certainly not needed by everyone with high cholesterol, they have been quite thoroughly tested and their side-effects are well-known and manageable.  For example, there is no statistical increase in liver failure among those on statin drugs vs. those not taking a statin.  However they do bump blood sugar up mildly and probably around 15% of folks get muscle aches that cause us to switch brands or take them off statins entirely.  So statins are neither the big answer nor the big villain; they’re just another tool.

We could go on, but you get the idea. As with most things, reality is a little more complicated than the myths.  It is often said that half of what we put forth as medical truth is false… and the trouble is we don’t know which half is which.  It should keep us humble, but it shouldn’t make us despair.  After all, for about 1900 years after Christ, the average life-span was stuck at about 38 years (partly because of the high number of infant and childhood deaths) whereas we’re at more than double that now.  Over time, if we follow the evidence and resist impatiently grabbing the newest too-good-to-be-true fix-all promises, we do arrive at some helpful realities.  In cholesterol management as with the rest of life, hang in there and keep holding out for the true and the good.

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Forgetting your daily medications or vitamins?

rx remind me

 

Rxmindme app

 

Walgreens has a great app you can download on your phone called Rxmindme http://download.cnet.com/RxmindMe-Prescription-Medicine-Reminder-and-Pill-Tracker/3000-2129_4-75311057.html   It’s a great way to set up reminders for medications or vitamins.

 

 

If medication has been prescribed by your healthcare provider there is an important reason they have recommended them.

If high blood pressure, diabetes, thyroid, cholesterol, asthma, etc. are not properly managed….there can be REAL consequences. If you have questions or concerns about medications, then schedule an appointment with your provider to discuss these concerns. Keep in  mind, there is a difference between allergic reaction and side effects. Or if you just simply don’t see the value or understand the importance of taking something that has been prescribed to you-be sure to discuss this with your provider. Sometimes there may be other options available.

This is a simple application to use and can be very beneficial for a variety of people. The most important thing is that you have your meds nearby when the app alarm goes off…..otherwise the reminder isn’t all that helpful. Try one of these handy pill boxes to keep things compact, organized and portable!

pill box

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(Not so) Good Old Pneumonia

“I’ve just been coughing up a little bit of junk … kind of sore in the chest when I do cough. I’ve got a bit of fever too. But overall I’m just really tired the last couple of days and winded when I go up the stairs. You think my smoking is finally catching up with me?” My mid-30’s patient turned out to have pneumonia affecting both sides of her lungs and proving somewhat slow in responding to antibiotics.

So what exactly is pneumonia?  Let’s start with what it’s not: a ton of what we see in a primary care office, especially this time of year, is in the category of upper respiratory infections (URI’s), and they’re usually viral.  An acute URI is a contagious infection of your upper respiratory tract which includes the nose, throat, larynx, and bronchial tubes. The common cold is the most well-known URI. Other types of URI’s include sinusitis, pharyngitis (throat infections), epiglottitis, and bronchitis.

Pneumonia on the other hand, is a lower respiratory infection.  It’s an infection of the lung itself, and can be either bacterial or viral.  In the United States, pneumonia causes more disease and death than any other infection.  Worldwide these infections cause a greater burden of disease than HIV infection, malaria, cancer, or heart attacks.  More than 3 million cases occur each year in the U.S. Pneumonia is more common during the winter months and in colder climates and often follows a viral URI which knocks down a person’s defenses.

In terms of its symptoms, pneumonia can be very similar to a bronchitis with coughing, fever, possibly some chest discomfort and shortness of breath, especially with exertion.  Some types of pneumonia have lots of sputum production (coughing up mucous) while others can have a dry cough.  Likewise, some will have a very high fever while others can have only low-grade or even no noticeable fever at all.

The substantial variation of symptoms is partly dependent on the particular bacteria or virus causing the infection and partly on the person who has the pneumonia.  For example, the elderly often don’t mount much of a fever response with pneumonia.  This variation of symptoms and substantial crossover with URI symptoms is also why we always like to get a good listen to the lungs of a patient with cough and other respiratory symptoms.  Often the lung exam will tell us if pneumonia is the problem.  The breath sounds of someone with a typical URI are usually pretty normal, while pneumonia often has crackles and wheezes coming from the infected parts of the lung.

In general, viral pneumonias more often have a dry cough while many (but not all) bacterial pneumonias have a productive cough with thick sputum.  Of course antibiotics only help the bacterial pneumonias.  That being said, over my course of some 30 years of practicing medicine, I have seen a steady increase in the resistance of bacteria to antibiotics.  The case we opened this article with is fairly typical in that we had to change antibiotics once and the improvement has been slow and steady, not fast and dramatic.

This growing resistance to antibiotics is part of the rationale for recommending pneumonia vaccines to appropriate individuals.  If you can be immunized against ever catching at least some of these pneumonias, it beats getting the pneumonia and then hoping it’s not resistant to multiple antibiotics.  There are currently two different pneumonia vaccines which are given from infancy all the way up to the elderly.  Your physician can let you know if you are in a category where one or both would be helpful.

If you end up still catching pneumonia, the majority can be treated outside of the hospital.  Mostly those who are very young, very old, have a lot of other health problems, or have an unusually severe case of pneumonia need to be treated in the hospital.

But here’s hoping you avoid pneumonia all-together and by some miracle even the URI’s that are moving like a tidal wave through our area.  You’ll help that with some old-fashioned preventives: good hydration, hand-washing, fruits and veggies, adequate rest, vaccination, aerobic exercise (really does improve immunity), and of course, not smoking.

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