Trigeminal Neuralgia and How It's Treated

Trigeminal neuralgia is an uncommon facial pain syndrome affecting a nerve in the head called the trigeminal nerve. It causes repeated episodes of sudden, extreme, pain like an electric shock on the side of the face. Trigeminal neuralgia is also called tic douloureux.

Trigeminal neuralgia pain cycles can last months. It can also lead to anxiety over when the pain will return.

What Is Trigeminal Neuralgia?

Trigeminal neuralgia is a facial pain condition caused by the trigeminal nerve, a cranial nerve that starts at the ear and runs along both sides of the face in three branches:

• Above the eye socket: the ophthalmic branch
• Along the cheekbone: the maxillary branch
• Along the jaw: the mandibular branch

The nerve sends sensory information from the face to the brain and helps control the chewing muscles.

Symptoms

The main symptom of trigeminal neuralgia is severe facial pain that comes on abruptly. The pain is often described as intensely sharp, stabbing, or electric shock-like. It occurs as repetitive bursts of pain that may last for a few seconds or up to two minutes. The bursts come on more frequently until the pain is almost constant.

Trigeminal neuralgia can affect any part of the face, but it is most common on the branches of the trigeminal nerve that run along the cheek and jaw. Typically, only one side of the face is effected.

The pain is often mistaken for toothache. Some people undergo painful and unnecessary dental procedures before getting an accurate diagnosis.

Pain flare-up cycles can persist for a few weeks or months, followed by extended pain-free periods that last months or even years. The course of a trigeminal neuralgia pain cycle is unpredictable. This can lead to anxiety and worry over when the next flare-up will strike.

Common Pain Triggers

During a pain cycle, certain common activities can trigger an episode of trigeminal neuralgia pain. These include:

• Brushing your teeth
• Chewing
• Exposure of your face to cold air
• Light touching of the face
• Shaving
• Smiling
• Talking or laughing
• Water running on your face
• Wind or breeze on your face

Causes

Trigeminal neuralgia is caused by compression of the trigeminal nerve root. Compression can occur from:

• An abnormal loop of an artery or vein in the face
• A cyst or tumor, like an acoustic neuroma or meningioma (rare)
• Inflammation of the nerve from a condition such as multiple sclerosis

The initial flare-up of trigeminal neuralgia often has no obvious cause. However, in some people, it can start after a car accident, dental work, or a blow to the face.

Risk Factors

Trigeminal neuralgia is more common in some demographics than others. While it can affect people of any age, race, or sex, it is more likely to affect:

• Females are affected slightly more often than males
• People over the age of 50
• People with multiple sclerosis

Trigeminal neuralgia does not typically run in families and is not believed to have a genetic component. However, about 2% of cases are found in people with a close relative with the condition. This is known as familial trigeminal neuralgia.

Diagnosis

Trigeminal neuralgia is typically diagnosed by a neurologist. Brain imaging, like magnetic resonance imaging (MRI), is often used to rule out other causes.

Conditions that trigeminal neuralgia may be confused with include:

• Postherpetic neuralgia (caused by shingles)
• Trauma to the trigeminal nerve
• Temporomandibular joint dysfunction (TMJ)
• Dental-related pain
• Cluster headaches

About 150,000 people in the United States are diagnosed with trigeminal neuralgia each year.

Treatment

Your healthcare provider will likely begin by prescribing medication to help control the pain, since trigeminal neuralgia doesn't usually respond to over-the-counter pain medication.

Medication

Trigeminal neuralgia is usually treated with an anti-seizure medication called Tegretol (carbamazepine). While often effective, it does have side effects, which are worsened with higher doses.

Side effects include:

• Drowsiness
• Dizziness
• Nausea
• Vomiting

Some people are unable to take carbamazepine due to more serious adverse effects. These can include:

• A significant decrease in the number of white blood cells (infection-fighting cells) after taking carbamazepine
• Aplastic anemia, a disorder that affects your bone marrow, where blood cells are produced (rare)
• Stevens-Johnson syndrome, also known as toxic epidermal necrolysis, a potentially fatal skin disorder

People of Asian descent, in particular, are at increased risk for Stevens-Johnson syndrome. Your healthcare provider may test you for a genetic marker before prescribing carbamazepine.

If you are unable to take carbamazepine, your healthcare provider may prescribe other medications. These include:

• Trileptal (oxcarbazepine), which is similar in structure to carbamazepine and may have fewer side effects
• Baclofen, a muscle relaxer
• Lamictal (lamotrigine), a medicine used to treat seizures and bipolar disorder

Surgery

If you continue to be affected by trigeminal neuralgia despite medical therapy, or if you cannot tolerate the side effects of medications, your neurologist may refer you for surgery.

Surgical treatments for trigeminal neuralgia include: 

• Microvascular decompression: An open surgery that involves the removal of a piece of the skull (craniotomy) to find and move the blood vessel compressing the trigeminal nerve. This is the most effective option, but also the most invasive.
• Percutaneous radiofrequency rhizotomy: The surgeon sends a heating current through a hollow needle inserted into the trigeminal nerve. This destroys nerve fibers and suppresses pain signals.
• Percutaneous balloon compression: The surgeon threads a balloon through a needle inserted into the cheek. The balloon is inflated to compress the nerve, injuring pain-causing fibers. 
• Percutaneous glycerol rhizotomy: Glycerol, a clear and thick liquid, is injected into the trigeminal nerve. This damages the nerve, which interferes with the transmission of pain signals. 
• Stereotactic radiosurgical procedures: Gamma Knife, Cyberknife, and Linear Accelerator (LINAC) are non-invasive procedures. They deliver a single, highly concentrated dose of ionizing radiation to the trigeminal nerve root.
• Neuromodulation: In peripheral nerve stimulation, motor cortex stimulation, and deep brain stimulation, electrodes are placed under the skull in the tissue near the nerve. Electrical stimulation is delivered to the parts of the brain responsible for sensations in the face. This relieves trigeminal neuralgia pain. 

Alternative Treatments

Some people with trigeminal neuralgia find relief with complementary and alternative medicine therapies.

These include:

• Acupuncture
• Biofeedback
• Chiropractic
• Nutrition therapy
• Vitamin therapy

However, there is little or no evidence to support any of these approaches for trigeminal neuralgia pain relief. They may, however, help relieve anxiety and depression associated with trigeminal neuralgia flare-ups. 

Coping

Living with trigeminal neuralgia can be unpredictable. Many people who live with this painful condition often experience anxiety, worrying over when the pain will strike next.

Mind-body exercises, such as yoga, meditation, aromatherapy, and visualization, can lower your anxiety and help you cope better.

Support groups focused on people who live with facial pain syndromes or chronic pain can help you learn additional coping techniques and feel less alone.

Summary

Trigeminal neuralgia is an extremely painful condition that causes waves of sharp facial pain. It is usually caused by compression on the trigeminal nerve, which runs alongside the face.

Pain cycles get increasingly more intense and can last days to weeks. Patients can go long durations without pain only to have the condition flare again.

Seizure medications or muscle relaxers may be recommended. In some cases, surgery is needed to end the pain. Mind-body therapies and support can help you cope with worry about your next flare.