Trigeminal Neuralgia

Trigeminal neuralgia causes sudden, severe facial pain that feels like an electric shock, often triggered by everyday activities like brushing teeth or touching the face. This chronic pain condition can be life-altering, but various treatments are available to help manage symptoms and restore quality of life.

Table of contents

• What is Trigeminal Neuralgia?
• The Trigeminal Nerve and Its Branches
• Symptoms and Pain Patterns
• Common Pain Triggers
• Causes and Types
• Who is Affected
• Diagnosis
• Treatment Options

tic douloureux

What is Trigeminal Neuralgia?

Trigeminal neuralgia is a chronic pain condition that causes intense, sudden episodes of facial pain^[1]. The pain is often described as feeling like an electric shock on one side of the face^[1]. Even light touch from simple activities like brushing your teeth or putting on makeup can trigger a jolt of severe pain^[1].

This condition is sometimes called tic douloureux, which is French for “painful tic”^[4]. It has also been referred to as “suicide syndrome” because the pain can become so unbearable that some people have considered taking their own lives^[13]. The condition is described by some as the most excruciating pain known to humanity^[4].

While trigeminal neuralgia is not life-threatening, it can be life-altering^[2]. The unpredictable nature of pain attacks can make even the simplest daily activities challenging. However, a diagnosis of trigeminal neuralgia does not mean living a life of constant pain. The condition can usually be managed with various treatment options^[1].

The Trigeminal Nerve and Its Branches

The trigeminal nerve is one of twelve cranial nerves in the head. It is the fifth cranial nerve and is responsible for providing sensation to the face^[3]. This nerve carries signals from the face to the brain^[1].

The trigeminal nerve has three distinct branches, which is why it gets its name from the Latin words “tria” (meaning three) and “geminus” (meaning twin)^[4]. These three branches control sensations in different parts of the face:

• The ophthalmic nerve (V1) controls sensation in the eye, upper eyelid, and forehead^[4]
• The maxillary nerve (V2) controls sensation in the lower eyelid, cheek, nostril, upper lip, and upper gums^[4]
• The mandibular nerve (V3) controls sensation in the jaw, lower lip, lower gums, and some of the muscles used for chewing^[4]

More than one nerve branch can be affected by trigeminal neuralgia, but the maxillary or mandibular branches are most commonly involved^[3]. The pain typically affects the lower face and jaw, although sometimes it affects the area around the nose and above the eye^[4].

• Trigeminal nerve
• Face
• Jaw
• Forehead
• Cheek
• Eye region
• Teeth and gums
• Brainstem

Symptoms and Pain Patterns

The main symptom of trigeminal neuralgia is sudden, intense pain in the face, usually on one side^[2]. The pain may feel like an electric shock or stabbing sensation^[2]. You may also experience facial muscle spasms during the attacks^[2].

Pain episodes typically last from a few seconds to several minutes^[1]. Some people experience short periods of intense shooting or jabbing pain, while others may have episodes lasting days, weeks, months, or longer^[1]. Some people have periods when they experience no pain at all^[1].

There are two main forms of trigeminal neuralgia based on how symptoms are experienced^[2]:

• Paroxysmal TN: This involves painful episodes that are sharp, intense, and sporadic. During an episode, pain and/or a burning sensation in the face can last anywhere from a few seconds to two minutes. Though there are pain-free breaks between episodes, attacks can continue for up to two hours^[2].
• TN with continuous pain: This type is less intensely painful but more frequent. People feel constant pain with stabbing and/or burning sensations, along with persistent aches and pains. This form of trigeminal neuralgia may be more difficult to manage^[2].

Between pain attacks, you may feel burning, throbbing, numbness, or dull achiness^[2]. In some cases, trigeminal neuralgia can get worse over time, with longer and more frequent pain attacks^[2].

Trigeminal neuralgia typically affects only one side of the face, a condition called unilateral pain^[2]. In rare cases, it can affect both sides of the face (bilateral) but not at the same time^[2]. When both sides are affected at different times, this is called bilateral trigeminal neuralgia^[3].

Common Pain Triggers

Simple activities that require you to move or touch your face can trigger painful episodes of trigeminal neuralgia^[2]. Common triggers include:

• Shaving, putting on makeup, or washing your face^[2]
• Eating and drinking^[2]
• Brushing your teeth, flossing, and using mouthwash^[2]
• Talking and smiling^[2]
• Touching the face, cheek, or jawline^[1]
• Chewing^[1]
• Encountering a light breeze or gust of wind on your face^[2]

Pain can also occur spontaneously without any obvious trigger^[3]. The unpredictable nature of these pain attacks can cause anxiety for many people with trigeminal neuralgia^[2]. Pain attacks rarely occur during sleep^[2].

Causes and Types

In general, pressure on or damage to the trigeminal nerve causes trigeminal neuralgia^[2]. The exact cause is still not completely understood, but the pain represents an irritation of the nerve^[4].

Healthcare providers categorize trigeminal neuralgia based on the specific cause^[2]:

Primary (classic) TN: This is the most common type. It happens when a blood vessel, usually the superior cerebellar artery, pushes on part of the trigeminal nerve root near the brainstem^[2]. This is called nerve compression. In 80% to 90% of cases, the nerve root is compressed by an adjacent artery or vein^[6]. This pressure on the nerve causes the protective covering of the nerve, called myelin, to break down (demyelination). This leads to abnormal nerve firing, which results in the development of irregular pain signals^[6].

Secondary TN: This type happens when another medical condition damages or affects the trigeminal nerve^[2]. Conditions that can cause secondary trigeminal neuralgia include:

• Multiple sclerosis (MS)^[2]
• A tumor^[2]
• Arteriovenous malformation (an abnormal tangle of blood vessels)^[2]
• A cyst^[4]
• Facial injury^[4]

Some patients initially seek help from dentists, mistaking the pain for a dental problem. This can lead to unnecessary dental work, such as root canals, before the correct diagnosis is made^[4].

Who is Affected

About 150,000 people in the United States receive a trigeminal neuralgia diagnosis every year^[2]. The condition is more common in certain groups of people.

Trigeminal neuralgia most often affects people over age 50, although it can occur at any age, including infancy^[3]. Most cases develop after age 50^[2]. The condition is more common in women than in men^[1]. Females are about twice as likely to develop it as males^[3].

Trigeminal neuralgia very rarely affects children^[2]. A form of trigeminal neuralgia is associated with multiple sclerosis^[4].

Diagnosis

Your healthcare professional diagnoses trigeminal neuralgia mainly based on your description of the pain^[7]. Important information includes:

• Type: Pain related to trigeminal neuralgia is sudden, feels like an electric shock, and is brief^[7]
• Location: The parts of your face affected by pain can help determine if the trigeminal nerve is involved^[7]
• Triggers: Activities like eating, talking, light touch of your face, or even a cool breeze can bring on pain^[7]

Diagnosing trigeminal neuralgia can be difficult, and it can take a few years for a diagnosis to be confirmed^[5]. Your facial pain may be caused by many different conditions, so an accurate diagnosis is important^[7].

Your healthcare professional may conduct tests to diagnose trigeminal neuralgia and help find the causes of the condition^[7]:

Neurological exam: Touching and examining parts of your face can help determine exactly where the pain is occurring. If you appear to have trigeminal neuralgia, the exam can help uncover which branches of the trigeminal nerve may be affected. Reflex tests can help determine if your symptoms are caused by a compressed nerve or another condition^[7].

Magnetic resonance imaging (MRI): You may need an MRI scan to look for possible causes of trigeminal neuralgia. An MRI may reveal signs of multiple sclerosis or a tumor. Sometimes a dye is injected into a blood vessel to view the arteries and veins to show blood flow^[7].

Your healthcare professional may also order other tests to rule out other conditions that can cause similar symptoms^[7].

Treatment Options

Trigeminal neuralgia treatment usually starts with medications, and some people don’t need any additional treatment^[7]. The first line of treatment for patients with trigeminal neuralgia is always medication^[10]. There is no cure for trigeminal neuralgia, but effective treatment methods exist for pain relief and minimizing symptoms^[13].

Medication

Standard painkillers like paracetamol and ibuprofen are not effective in treating trigeminal neuralgia^[5]. Instead, you’ll usually be prescribed an anticonvulsant, a type of medicine originally used to treat epilepsy^[5]. These medications can help relieve nerve pain by slowing down electrical impulses in the nerves and reducing their ability to send pain messages^[5].

The most commonly prescribed anticonvulsant for trigeminal neuralgia is carbamazepine, which can provide at least partial pain relief for up to 80% to 90% of patients^[10]. Carbamazepine is currently the only medicine licensed to treat trigeminal neuralgia in the UK^[11].

Other anticonvulsants frequently prescribed for trigeminal neuralgia include^[10]:

• Phenytoin
• Gabapentin
• Lamotrigine
• Oxcarbazepine
• Topiramate
• Pregabalin

The muscle relaxant baclofen can also be prescribed, alone or in combination with other drugs^[10]. In some cases, Botox injections or steroids may also be prescribed^[16].

Anticonvulsants need to be taken regularly, not just when pain attacks happen^[5]. Many people can manage trigeminal neuralgia pain for years with these medications^[13]. However, commonly experienced side effects include dizziness, drowsiness, forgetfulness, unsteadiness, and nausea^[10]. Over time, some people find that medications become less effective, requiring higher doses or multiple medications taken together^[7].

Surgical and Procedural Options

If medications do not adequately control symptoms or cause serious side effects, your doctor may recommend more advanced treatment options^[16]. Surgery is reserved for people who still experience debilitating pain despite best medical management^[10].

Nerve blocks involve injecting numbing medications near the affected nerve to help block pain signals^[16].

Other treatment options include^[16]:

Balloon compression: A surgical procedure in which a balloon is used to gently press against the trigeminal nerve to relieve pain.

Glycerol injections: Also called percutaneous glycerol rhizolysis, this involves injecting glycerol into the trigeminal nerve using special X-ray guidance to help calm down nerve fibers that cause pain.

Radiofrequency ablation: Also called percutaneous radiofrequency rhizotomy, this surgical technique directs high-frequency heat at the trigeminal nerve, destroying its ability to transmit pain signals to the brain.

Microvascular decompression (MVD): This is the most common surgical procedure for treating trigeminal neuralgia^[10]. During MVD, a surgeon relieves pressure on the nerve by placing a small pad made of Teflon between the nerve and the compressing blood vessel^[10]. This procedure is more suited for younger patients who can tolerate surgery and offers longer-lasting pain relief^[16]. Studies indicate that about 80% of MVD surgeries have a successful outcome for people with trigeminal neuralgia^[13].

Radiation therapy: This option, also called stereotactic radiosurgery or gamma knife, involves targeting the trigeminal nerve with precise, high-dose radiation to reduce pain. It may be used for people who are not candidates for surgery or who have not found relief from other treatments. However, it may take several weeks for this treatment to be effective^[16].

A healthcare provider can recommend the best treatment options for each person on a case-by-case basis^[13]. There is no one-size-fits-all solution to this condition.