Trigeminal neuralgia (TN) is the most common cause of facial pain, affecting an estimated 12 individuals out of 100,000, each year. This challenging pain disorder usually affects patients over 50 years, mostly women. However, it may appear in younger patients, especially those with multiple sclerosis. Pain starts after an injury to the trigeminal nerve, a major nerve that provides sensation to the face.
Patients describe TN as an “electric shock” or “stabbing” pain. This condition, if untreated, progresses to the point where basic functions like chewing or talking can trigger severe pain. You should see your pain specialist, early in the course of this disorder. Timely treatment with medications and minimally-invasive procedures can alleviate the pain before it reaches unbearable levels.
The trigeminal nerve has three branches. One branch provides feeling to the top of the face and eye area, another to the mid-face, and a third to the jaw. Pain symptoms differ among individuals, depending on which of the three branches is injured.
- Extreme, electric-like or shooting face pain.
- Constant aching or burning sensations that change into a spasm-like pain.
- Cheek, jaw, tooth, gum, lip, eye, or forehead pain.
- One-sided face pain (there is a trigeminal nerve on each side of the face; usually only one nerve is injured).
- Occasionally, pain may affect both sides of the face (if both trigeminal nerves are injured).
- Sudden attacks of pain triggered by touch, chewing, speaking, or teeth brushing.
- Episodic pain that lasts from a few seconds to several minutes.
- Pain that lasts for days, weeks, months or longer (can be followed by pain-free periods).
- Washing your face
- Applying makeup
- Brushing your teeth
- Blowing your nose
- Drinking hot or cold beverages
TN can start in several ways:
- A nearby blood vessel presses on the trigeminal nerve, as the nerve exits the brain stem. (This is the part of the brain that connects with the spinal cord). The pressure damages the nerve’s protective coating.
- TN occurs in people with multiple sclerosis, a disease that brakes down nerves’ protective coating.
- A tumor presses on the nerve.
- Trigeminal nerve injury after sinus surgery, dental procedures, stroke, or facial trauma.
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When to see a doctor
You should seek treatment as soon as possible. Trigeminal nerve pain can progress to the point where basic daily functions like chewing or speaking are unbearable. Doctors trained to diagnose and treat TN span a number of specialties: pain management, neurology, and neurosurgery.
A pain specialist will treat you with a combination of medications and procedures such as nerve blocks and nerve stimulator implants. A neurologist also provides medications, while neurosurgeons offer more invasive treatments.
Your pain specialist will diagnose TN based on your pain symptoms and neurologic exam while using a stepwise approach:
- Find a pain pattern – Is your pain shooting and electric like? Is it episodic or constant?
- Perform a neurological exam – Your pain specialist tests for numbness, pain, and abnormal reflexes in the face. The exam reveals which nerve branch triggers your pain.
- Rule out other causes of facial pain – A number of other disorders cause face pain: shingles, cluster headaches, or strain in the jaw joint and muscles.
- Use imaging tests to find the exact cause for the trigeminal nerve pain – A magnetic resonance imaging (MRI) scan can rule out a tumor or multiple sclerosis. A magnetic resonance angiogram (MRA) can and show if one is compressing the nerve.
- Start a medication trial – Decreased pain after a trial with anticonvulsants or antidepressants, confirms a diagnosis of TN.
- Treatment starts with the least invasive option, medications.
- It then proceeds to minimally-invasive procedures, offered by a pain specialist.
- Surgery is used early on in some situations, such as the removal of blood vessels that compress the nerve. Otherwise, surgery is typically used later in the treatment sequence.
- Anticonvulsants – These medications block nerve pain signals from reaching the brain. The pain relief benefits have to be weighed against the side effects (dizziness, double vision, drowsiness, and nausea). These drugs include carbamazepine, gabapentin, and others.
- Tricyclic antidepressants – Medications such as amitriptyline or nortriptyline work by altering chemical levels in your brain and decreasing pain sensations.
- Common analgesics and opioids – Opioids are not usually helpful in treating the episodic, sharp pain caused by the most common form of TN. Some individuals with a less common form of TN (constant pain rather than episodic) may improve with opioids. However, prolonged use is discouraged due to abuse potential and decreased efficacy over time.
- Muscle relaxants – Medications, such as baclofen, are used alone or in combination with anticonvulsants, for increased efficacy. Side effects include confusion, nausea, and drowsiness.
Side effects or a decrease in efficacy can limit the use of some medications. At this point, your pain specialist can offer you several effective, minimally invasive treatments.
- Nerve blocks – These injections contain a pain-numbing medicine that blocks nerve pain. This treatment breaks the pain cycle for a couple of hours, several days, or longer.
- Trigeminal ganglion pulsed radiofrequency (RF) – RF pulses travel through a needle to the painful nerve. They decrease pain signal release from the nerve.
- Radiofrequency thermocoagulation – Heat lesions the nerve and stops pain signals.
- Peripheral nerve stimulation (PNS) – This is an established technique, invented in the 1960s. A pain specialist places a small electrical wire next to the trigeminal nerve. The wires deliver electrical pulses that change a person’s ability to feel pain. A patient merely feels mild, buzzing sensations. The patient controls the strength of the electrical pulses by remote control.
A large number of patients report pain relief after surgery.
- Microvascular decompression – This surgery is common and generally effective. It is used when a blood vessel is compressing the trigeminal nerve. A surgeon moves the blood vessel away from the nerve. Given the sensitive nature of the surgery, there is a risk of hearing problems, facial weakness, and numbness.
- Gamma knife surgery – This surgery does not require a skin incision. It simply delivers radiation to lesion the painful nerve. Over the course of a month, pain signals to the brain decrease. However, facial numbness is a possible side effect.
- Percutaneous stereotactic rhizotomy – A surgeon uses heat to destroy some of the nerve fibers that carry pain signals to the brain. A similar procedure (glycerol rhizotomy), uses a chemical to destroy the painful nerve fibers.
- Percutaneous balloon compression – A surgeon introduces a thin tube through the cheek, and then places a tiny balloon in the trigeminal nerve. Pressure from the balloon injures the nerve fibers, causing them to stop sending pain signals.
If you suffer from facial pain due to trigeminal neuralgia, we encourage you to contact one of our competent NSPC doctors. We will work with you to find the best treatment for your unique situation. Click here for an appointment.