What Is Trigeminal Neuralgia?

Do you often experience intense face pain, stopping you from completing tasks and affecting your overall physical and mental well-being? If so, there is a chance that you may have trigeminal neuralgia.

Trigeminal neuralgia is a disease that results in intense, often unbearable facial pain resulting from a pinched nerve inside your skull. While the symptoms can feel overwhelming, there are treatments available such as medication and surgery that may provide temporary relief. 

Continue reading if you would like to find out more about trigeminal neuralgia, what types exist, what causes it, as well as how it is diagnosed and treated. 

Overview

Trigeminal neuralgia, also referred to as tic douloureux, is a rare condition that involves frequent episodes of intense face pain that can feel overwhelming both physically and mentally and be highly incapacitating.^1,2

Trigeminal neuralgia is caused by pressure being exerted on the trigeminal nerve, usually by a blood vessel, though it can also result from a tumor or a cyst.^3,4 The trigeminal nerve is part of a group of cranial nerves in the head that gives sensation to the face. Trigeminal neuralgia is sometimes progressive, meaning that episodes may become more frequent and severe over time.¹ 

Types of trigeminal neuralgia

Depending on the intensity and duration of the attacks, trigeminal neuralgia is divided into two types:¹

• Type 1 is known as classic trigeminal neuralgia and it is the most common form of the condition. Attacks are usually short, with episodes lasting between a couple of seconds to two minutes and causing intense pain accompanied by a burning or shock-like sensation. The pain may affect your mouth, nose, cheek, or other parts of one side of your face.²  Only a short time may pass between attacks and it can occur frequently, even up to two hours at a time. The pain can be localized or spread across a larger area of the face. Episodes of pain are infrequent during sleep. The severity of the pain may cause people to avoid their usual activities or social interactions due to fear of experiencing an attack.
• Type 2 is known as atypical trigeminal neuralgia and it is less common than Type 1. It usually results in pain that is less intense than that caused by Type 1. Instead, you may feel a constant, dull, burning pain. 

Despite this distinction, you may experience both types, possibly at the same time. It is not clear what causes you to have one type over the other.²

Signs and symptoms of trigeminal neuralgia

If you have trigeminal neuralgia, the most obvious sign is sudden attacks of intense, pulsating, stabbing pain affecting your face, often referred to as facial pain.⁵ They are described as shock-like, with the pain being so severe that it may stop you from doing anything else. Attacks may be followed by less intense, burning-like pain. 

Trigeminal neuralgia most often affects your teeth, jaw, or cheek, though you can also feel pain in your forehead or eyes. It usually causes unilateral pain (pain on one side of the face at a time).

Episodes may repeat during periods lasting anywhere between days and months. In the worst cases, you may experience them hundreds of times daily. In some cases, you may not experience any attacks for months or even years.  

Causes of trigeminal neuralgia

Depending on what is thought to cause your trigeminal neuralgia, it will be classified as

• Classical: caused by pressure on the trigeminal nerve
• Secondary: caused by an underlying condition affecting the trigeminal neuralgia
• Idiopathic: the cause is unknown

Type 1 trigeminal neuralgia is most often classical, resulting from pressure on the trigeminal nerve. This is also the case for Type 2 trigeminal neuralgia, though it may also be caused by another condition (secondary). Both types can be idiopathic.² 

Classical trigeminal neuralgia

This is the result of pressure being placed on the trigeminal nerve. This is most often caused by a blood vessel like an artery or a vein. Not everyone with a compressed trigeminal nerve will experience pain. The reason behind this is not clear.  

Secondary trigeminal neuralgia

This is the result of another condition, such as:

• A tumour
• A cyst
• Multiple sclerosis
• A tangle of malformed blood vessels
• Face injury
• Surgery-related injuries, such as dental surgery

Idiopathic trigeminal neuralgia

If no cause behind your trigeminal neuralgia is identified, your case will be referred to as idiopathic trigeminal neuralgia.

Management and treatment for trigeminal neuralgia

While trigeminal neuralgia can severely impact your physical and mental health, treatments can give you temporary pain relief, some relieving you of pain for years or even decades. Treatment typically involves medication and surgery.¹

Medication

There are many types of medication available to address trigeminal neuralgia, including

• Antidepressants, though also used to treat depression, are often prescribed to alleviate chronic pain, such as the one caused by trigeminal neuralgia. Commonly prescribed antidepressants include amitriptyline and nortriptyline. 
• Anticonvulsants are often used to treat seizures, but can also treat trigeminal neuralgia. They are more effective in treating Type 1 than Type 2 trigeminal neuralgia. They include carbamazepine, topiramate, clonazepam, lamotrigine, and valproic acid.

Common medications used to treat pain such as aspirin and ibuprofen, as well as opioids such as hydrocodone, are usually not effective in treating the intense pain of Type 1 trigeminal neuralgia. 

Surgery

If medication does not address your pain or causes undesirable side effects, you may be eligible for surgery. There are different types of surgery available, and which one you and your doctor may opt for depends on your particular case of trigeminal neuralgia, the type of pain you are experiencing, your overall health, and your medical history. Your personal preference will also be considered. 

A rhizotomy, or rhizolysis, is a surgical intervention where nerves are damaged to stop them from producing pain. This usually results in some facial numbness. In the case of trigeminal neuralgia, this is achieved in many ways, such as:

• Balloon compression employs a small balloon tip on a thin tube known as a catheter to block the nerve. Balloon compression may give you pain relief for one to two years. 
• Glycerol injection uses a chemical called glycerol. Like balloon compression, pain relief may last up to two years. It can be repeated more than once if symptoms return.
• Radiofrequency thermal lesioning uses heat to stop the nerves from firing and may need to be repeated to reduce pain to a level you find tolerable while still maintaining sensation. You may have your pain not return, while about one in two people experience pain relief for three or four years.
• Stereotactic surgery, sometimes known as gamma knife or cyberknife, uses precise imaging technology to point radiation beams to a specific part of the trigeminal nerve. Unlike other rhizotomy techniques, stereotactic surgery does not require anesthesia. About one in every two people undergoing the procedure experience pain again within three years. 

Most rhizotomies are outpatient, meaning you may not need to stay in the hospital after the procedure. For stereotactic radiosurgery, there is a chance you may need to stay overnight. 

Microvascular decompression, known as MVD, is an alternative to rhizotomy. It is more invasive but has the lowest chance of pain coming back. During MVD, a soft cushion or pad is placed between the nerve and the blood vessel pressing against it. The procedure usually requires you to stay in the hospital and is carried out under anesthesia. In one out of two people, pain relief is permanent, while for others pain may take up to 15 years to return. If no blood vessel is found to be compressing the nerve, a neurectomy will be performed instead. This involves cutting the nerve at a specific location to prevent it from producing pain.

Side effects of these procedures include:

• Hearing loss
• Problems keeping balance
• Infection
• Leaking cerebrospinal fluid (clear fluid in the brain) 
• Anesthesia dolorosa (painful numbness)
• Stroke (rare)  

Diagnosis of trigeminal neuralgia

Diagnosing trigeminal neuralgia typically involves checking for any symptoms. If you are experiencing facial pain, your doctor will ask questions about the nature of the attacks, including duration and frequency as well as the parts of your face that it affects.⁶ Your doctor may also try to identify where in your head and jaw you are experiencing pain.

The aim is to ensure that the pain is not caused by other conditions that may cause similar pain, such as:

• Jaw or dental problems - Since the symptoms of trigeminal neuralgia commonly affect the jaw, teeth, and gums, you may likely visit a dentist before going to the doctor to rule out any dental issues causing your pain, such as an infection or a cracked tooth.
• Cluster headaches - the pain may sometimes affect the face.
• Post-herpetic neuralgia - a type of chronic pain caused by shingles. 

Your doctor may also ask you questions regarding your medical and family history to identify the underlying cause of your symptoms. 

You may be referred to a specialist if your doctor suspects that you have trigeminal neuralgia. This can involve additional tests, such as an MRI scan that may help detect whether a blood vessel is compressing the trigeminal nerve, as well as whether any other conditions cause the cause facial pain, such as, but not limited to:

• Sinusitis
• A tumor on a facial nerve
• Nerve damage related to multiple sclerosis

It can take years to diagnose trigeminal neuralgia. 

FAQs

Can trigeminal neuralgia be prevented?

There is no known way to prevent trigeminal neuralgia, though you may try to avoid activities that increase the chances of you getting an attack.⁷

How common is trigeminal neuralgia?

Trigeminal neuralgia is a rare condition.⁸ It is unclear how many people are affected by trigeminal neuralgia at any given time, though it is more likely to affect people assigned to females at birth (AFAB). 

Trigeminal neuralgia most commonly begins to show symptoms between the ages of 50 and 60. 

Who is at risk of trigeminal neuralgia?

Some conditions increase the chance of developing trigeminal neuralgia. You may be at higher risk of trigeminal neuralgia if you have been diagnosed with a tumor, a cyst, or multiple sclerosis. Please refer to the “Causes of trigeminal neuralgia” section for further details.

When should I see a doctor?

Please see a doctor if you experience constant or frequent facial pain, especially if painkillers do not give you relief and your dentist has not identified a dental condition.⁵ Your doctor will then try to identify the root cause by inquiring about your symptoms and excluding the possibility of other conditions that may be behind them. 

Summary

Trigeminal neuralgia is a disease that involves recurring attacks of intense facial pain. As a result, living with the condition can be challenging and have a significant impact on your quality of life and mental health, including unintended weight loss and depression.⁵ Though permanent pain relief is not guaranteed, there are treatments available that may provide temporary relief. 

If you have been diagnosed with trigeminal neuralgia, please be aware that there are local and national organizations that may provide you with support and information on the condition, such as the Trigeminal Neuralgia Association UK.