Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating pain. You may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of searing pain. Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50. Because of the variety of treatment options available, having trigeminal neuralgia doesn't necessarily mean you're doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery.
Causes of Trigeminal Neuralgia
In trigeminal neuralgia, also called tic douloureux, the trigeminal nerve's function is disrupted. Usually, the problem is contact between a normal blood vessel — in this case, an artery or a vein — and the trigeminal nerve, at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction. Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. Less commonly, trigeminal neuralgia can be caused by a tumor compressing the trigeminal nerve. In other cases, a cause can't be found.
A variety of triggers may set off the pain of trigeminal neuralgia, including:
Stroking your face
Brushing your teeth
Putting on makeup
Encountering a breeze
Signs & Symptoms of Trigeminal Neuralgia
Trigeminal neuralgia symptoms may include one or more of these patterns:
Occasional twinges of mild pain
Episodes of severe, shooting or jabbing pain that may feel like an electric shock
Spontaneous attacks of pain or attacks triggered by things such as touching the face, chewing, speaking and brushing teeth
Bouts of pain lasting from a few seconds to several seconds
Episodes of several attacks lasting days, weeks, months or longer —some people have periods when they experience no pain
Pain in areas supplied by the trigeminal nerve (nerve branches), including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
Pain affecting one side of your face at a time
Pain focused in one spot or spread in a wider pattern
Attacks becoming more frequent and intense over time
Diagnosis of Trigeminal Neuralgia
A diagnosis of trigeminal neuralgia is primarily based on a description of your pain, including the:
Type. Pain related to trigeminal neuralgia is sudden, shock-like and brief.
Location. The parts of your face that are affected will tell your doctor if the trigeminal nerve is involved.
Triggers. Trigeminal neuralgia-related pain is typically brought on by light stimulation of the cheeks, such as from eating, talking or even encountering a cool breeze.
Tests used to confirm the diagnosis may include:
A neurological examination. Touching and examining parts of your face can help your doctor determine exactly where the pain is occurring and — if you appear to have trigeminal neuralgia — which branches of the trigeminal nerve may be affected.
Magnetic resonance imaging (MRI). An MRI scan of your head can show if multiple sclerosis is causing trigeminal neuralgia.
Facial pain can be caused by many different disorders, so an accurate diagnosis is important. Your doctor may order additional tests to rule out other conditions.
Treatments of Trigeminal Neuralgia
Trigeminal neuralgia treatment usually starts with medications, and many people require no additional treatment. However, over time, some people with the disorder eventually stop responding to medications, or they experience unpleasant side effects. For those people, injections or surgery provide other trigeminal neuralgia treatments options.
Medications to lessen or block the pain signals sent to your brain are the most common initial treatment for trigeminal neuralgia.
Anticonvulsants. Carbamazepine (Tegretol, Carbatrol) is the drug most commonly prescribed — and with the most demonstrated effectiveness — for trigeminal neuralgia. Other anticonvulsant drugs used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal), phenytoin (Dilantin, Phenytek) and gabapentin (Neurontin).
If the anticonvulsant you're using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness, double vision and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.
Antispasmodic agents. Muscle-relaxing agents such as baclofen may be used alone or in combination with carbamazepine or phenytoin. Side effects may include confusion, nausea and drowsiness.
Alcohol injections provide temporary pain relief by numbing the affected areas of your face. Your doctor will inject alcohol into the part of your face corresponding to the trigeminal nerve branch causing pain. The pain relief isn't permanent, so you may need repeated injections or a different procedure in the future. Side effects may include infections at the injection site, bleeding and damage to nearby nerves.
The goal of surgery for trigeminal neuralgia is either to stop the blood vessel from compressing the trigeminal nerve or to damage the trigeminal nerve to keep it from malfunctioning. Damaging the nerve often causes temporary or permanent facial numbness, and with any of the surgical procedures, the pain can return months or years later.
Surgical options for trigeminal neuralgia include:
Gamma-knife radiosurgery (GKR). This procedure involves delivering a focused, high dose of radiation to the root of the trigeminal nerve. Because of GKR's effectiveness and safety compared with other surgical options for trigeminal neuralgia, the procedure is becoming widely used and may be offered earlier than other surgical procedures. Gamma-knife radiosurgery uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and can take several weeks to begin. GKR is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Fewer than 5 percent of people who undergo this procedure experience side effects, which may include lasting loss of facial sensation. The procedure is painless and typically is done without anesthesia.
Microvascular decompression (MVD). This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root. During MVD, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, part of your brain is lifted to expose the trigeminal nerve. Any artery in contact with the nerve root is directed away from the nerve, and the surgeon places a pad between the nerve and the artery. If a vein is compressing the nerve, the surgeon typically will remove it. MVD can successfully eliminate or reduce pain most of the time, but pain can recur in some people. While MVD has a high success rate, it also carries risks. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, and even a stroke or death. Most people who have this procedure have no facial numbness afterward. Note that if no artery or vein appears to be compressing the nerve, your surgeon may sever part of the nerve, instead. This procedure is called a rhizotomy.
Glycerol injection. During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. The needle is guided into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Images are made to confirm that the needle is in the proper location, and then a small amount of sterile glycerol is injected. After three or four hours, the glycerol damages the trigeminal nerve and blocks pain signals. Initially, this procedure relieves pain in most people. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.
Balloon compression. In balloon compression of the trigeminal nerve, your doctor inserts a hollow needle through your face and into an opening in the base of your skull. Then, a thin, flexible tube (catheter) with a balloon on the end is threaded through the needle. The balloon is inflated with enough pressure to damage the nerve and block pain signals. Balloon compression successfully controls pain in most people, at least for a while. Most people undergoing this procedure experience some facial numbness, and some experience temporary or permanent weakness of the muscles used to chew.
Electric current (radiofrequency thermal rhizotomy). This procedure selectively destroys nerve fibers associated with pain. While you're sedated, your doctor places a hollow needle through your face and into an opening in your skull. Once the needle is positioned, an electrode is threaded through it to the nerve root. You're then awakened from sedation so that you can indicate when and where you feel tingling from the mild current pulsed through the tip of the electrode. When the neurosurgeon locates the part of the nerve involved in your pain, you are returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn't eliminated, your doctor may create additional lesions. Almost everyone who undergoes radiofrequency thermal rhizotomy has some facial numbness after the procedure.
Severing the nerve (rhizotomy). A procedure called partial trigeminal rhizotomy involves cutting part of the trigeminal nerve at the base of your brain. Through an incision behind your ear, your doctor makes a quarter-sized hole in your skull to access the nerve. Because it cuts the nerve at its source, your face will be numb permanently.
When to seek Medical Advice
If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over-the-counter pain relievers, see your doctor.