Trigeminal Neuralgia

What is trigeminal neuralgia?

Trigeminal neuralgia (TN) causes episodes of intense facial pain that can disrupt your everyday activities. It typically happens when a blood vessel puts pressure on your trigeminal nerve near your brainstem. This nerve provides sensation to your head and face. Trigeminal neuralgia is a type of neuropathic pain.

Trigeminal neuralgia isn’t life-threatening, but it can be life-altering. Activities as simple as chewing, talking, smiling and brushing your teeth can trigger brief bouts of intense pain, making TN both a physical and emotional condition. TN is typically chronic (long-term) but several treatments can help manage your symptoms.

Another name for trigeminal neuralgia is tic douloureux.

How common is trigeminal neuralgia?

About 150,000 people in the U.S. receive a trigeminal neuralgia diagnosis every year. People assigned female at birth (AFAB) are more likely to develop it than people assigned male at birth (AMAB). Most cases develop after age 50. Trigeminal neuralgia very rarely affects children.

What are the symptoms of trigeminal neuralgia?

The main symptom of trigeminal neuralgia is sudden, intense pain in your face — usually on one side. The pain may be an electric shock-like or stabbing sensation. You may also have facial muscle spasms during the attacks. In between pain attacks, you may feel the following sensations:

• Burning.
• Throbbing.
• Numbness.
• Dull achiness.

There are two main forms of trigeminal neuralgia based on how you experience symptoms:

• Paroxysmal TN: You experience painful episodes that are sharp, intense and sporadic. During an episode, you may feel pain and/or a burning sensation in your face that can last anywhere from a few seconds to two minutes. Though there will be pain-free breaks in between episodes, this can continue for up to two hours.
• TN with continuous pain: This type is less painful and intense, but the pain is more frequent. You feel constant pain, notably stabbing and/or burning sensations, along with persistent aches and pains. With atypical trigeminal neuralgia, you may have more difficulty managing the symptoms.

Typically, trigeminal neuralgia is unilateral, meaning it only affects one side of your face. In rare cases, it can affect both sides of your face (bilateral) but not at the same time. In some cases, trigeminal neuralgia can get worse over time with longer and more frequent pain attacks.

Trigeminal neuralgia symptom triggers

It’s mostly simple activities that require you to move or touch your face that can trigger painful TN episodes, including:

• Shaving, putting on makeup or washing your face.
• Eating and drinking.
• Brushing your teeth, flossing and using mouthwash.
• Talking and smiling.
• Applying any pressure to your face, especially to your cheek or jawline.
• Encountering a light breeze or gust of wind on your face.

The pain attacks rarely occur during sleep.

What causes trigeminal neuralgia?

In general, pressure on or damage to your trigeminal nerve causes TN. Healthcare providers categorize trigeminal neuralgia based on the specific cause:

• Primary (classic) TN: This type happens when a blood vessel (usually the superior cerebellar artery) pushes on part of the trigeminal nerve root (nerve compression). It’s the most common cause.
• Secondary TN: Secondary TN happens when another condition damages or affects your trigeminal nerve, like multiple sclerosis (MS), a tumor or arteriovenous malformation. People with secondary TN are more likely to be younger and have pain on both sides of their faces. Only 15% of TN cases are secondary.
• Idiopathic TN: Providers diagnose idiopathic TN when there’s no clear cause of your facial pain after doing diagnostic tests.

What are the risk factors for trigeminal neuralgia?

Factors that may increase your risk of developing TN include:

• High blood pressure.
• Smoking.
• Aging.
• Female sex.
• Having a biological family history of TN.

How is trigeminal neuralgia diagnosed?

To start, your healthcare provider will ask you about your symptoms and medical history. They’ll do a physical exam of your head and neck area and a neurological exam. They’ll likely make their diagnosis based on a few different factors, like:

• The specific type of pain you’re feeling.
• The exact spot on your face where you feel pain.
• Which activities or actions trigger a painful episode.

Many conditions have facial pain as the main symptom, so your provider will need to rule them out. Examples include cluster headaches, migraines, postherpetic neuralgia and TMJ dysfunction.

Your provider may recommend a brain MRI to figure out what exactly is causing TN, like pressure from a blood vessel or a tumor.

What is the treatment for trigeminal neuralgia?

Healthcare providers use a combination of medications, surgery and other therapies to treat trigeminal neuralgia. It may take time to find the best approach for you.

Medication for trigeminal neuralgia

Medication is often the first therapy your provider will suggest for primary (classic) and idiopathic TN. They include:

• Antiseizure medications: These medications can block pain signals. Providers often start with carbamazepine or oxcarbazepine. They manage pain for most people in the early stages of TN. But their effectiveness can decrease over time. Other medications in this drug class include gabapentin, pregabalin, lamotrigine, lacosamide, topiramate and phenytoin.
• Baclofen: This is a muscle relaxant.

Each of these medications has certain side effects. Together, you and your provider will decide which option is best for you.

Surgery for trigeminal neuralgia

Providers typically only consider surgery as a treatment for TN if:

• Medication doesn’t work to manage your symptoms.
• You have secondary TN (like a tumor pressing on your nerve).

Surgical options for TN vary in complexity and have a range of risks and side effects. Your provider will go over all the considerations with you. Surgical options for TN include:

• Microvascular decompression: This surgery involves relieving pressure from blood vessels that are pressing against your trigeminal nerve. It’s the most invasive surgery for TN. But it’s also the most effective at preventing pain long-term.
• Radiosurgery: This procedure involves focusing radiation on the root of your trigeminal nerve to block pain signals. It may take over a month to experience pain relief from this procedure.
• Rhizotomy: This procedure involves intentionally damaging the root of your trigeminal nerve to block pain signals. There are several methods providers use to do this, including mechanical balloon compression, thermocoagulation and chemical injection. This procedure always results in some degree of facial sensory loss and numbness. It may relieve pain for a few years but is typically less effective long-term.
• Peripheral neurectomy: This procedure involves damaging or removing a peripheral branch of your trigeminal nerve. Surgeons can do this through alcohol injection, incision (a cut), cryotherapy or radiofrequency lesioning.

Other treatments for trigeminal neuralgia

Your provider may recommend other treatments for trigeminal neuralgia pain management — usually in combination with medication. They include:

• Botulinum toxin injections or nerve blocks. These provide temporary pain relief.
• Acupuncture.
• Biofeedback.
• Psychotherapy (talk therapy).
• Yoga.
• Meditation.
• Aromatherapy.

What can I expect if I have trigeminal neuralgia?

Trigeminal neuralgia affects people differently. So, it’s difficult to predict how TN will affect you. Some people have a series of episodes that last for weeks or months, followed by pain-free periods. Others have persistent background facial pain in addition to pain attacks. For some, the pain attacks worsen over time. In addition, medications for TN might lose effectiveness over time.

For all of these reasons, it’s important to check in with your healthcare provider regularly about how TN is affecting you and if your treatment plan is working. You don’t have to live in constant pain.

What are the possible complications of trigeminal neuralgia?

The pain of trigeminal neuralgia is so severe that it can greatly affect your mental health and everyday life. People with TN are at risk of experiencing:

• Depression.
• Anxiety.
• Social isolation.

It’s crucial to seek professional help if TN is affecting your mental health. Reach out to your healthcare provider or a mental health professional, like a psychologist.

The treatments for TN may also lead to complications. Long-term use of antiseizure medications can cause issues like osteoporosis. Surgical procedures for TN can also lead to complications, like permanent facial numbness.

When should I see my healthcare provider?

No one should have to live with frequent pain attacks. See your healthcare provider if you develop intense pain in your face. If you have TN, you’ll likely need to see your provider regularly to make sure your treatment plan is working for you.

What questions should I ask my healthcare provider?

It may be helpful to ask your healthcare provider the following questions about trigeminal neuralgia:

• What caused trigeminal neuralgia?
• What type of TN do I have?
• What can I do to reduce pain when I have to touch or move my face?
• What are my treatment options?
• What are all the pros and cons of my treatment options?
• Are there support groups for people with trigeminal neuralgia?