Trigeminal Neuralgia

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  1. Overview
  2. Causes
  3. Symptoms
  4. Diagnosis
  5. Treatment
  6. Helpful Tips
  7. Additional Resources
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Overview

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal nerve. This nerve is responsible for sensation in the face, including the mouth.

TN causes episodes of sudden extreme electric shock-like, shooting, stabbing or sharp pain in the face. There are two types of TN. In Type 1 TN, the pain is typically felt on one side of the face, usually the right. These intense flashes of pain can be triggered by a light touch, such as when washing the face or shaving, when brushing teeth, eating, drinking, talking, or being exposed to cold air. In general, the pain lasts from less than a second up to several minutes. Sometimes, people have multiple episodes of pain that can last up to one hour.

People with Type 2 TN have constant aching, burning, and stabbing pain that is usually less severe than Type 1 TN. People can experience both types of pain at the same time.

While some TN sufferers have continuous pain, most people experience a pattern of pain that worsens and then stops for some time. Pain-free periods can last months or years. However, TN attacks often worsen over time, with fewer and shorter pain-free periods before they recur. Because pain can occur in the upper or lower jaw, people may go to the dentist thinking they have a dental issue. Although the pain from TN is not life threatening, it is very severe and can be both physically and mentally disabling.

TN occurs most often in people over age 50, but it can occur at any age, and is more common in women.

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Causes

Trigeminal neuralgia may be caused by a blood vessel (artery or vein) pressing on the trigeminal nerve. This pressure causes the protective coating around the nerve—the myelin sheath—to wear away or become damaged. As a result, the nerve does not work as it should.

Trigeminal neuralgia may also occur because of other underlying diseases. When other diseases cause TN, it is called “secondary trigeminal neuralgia.” Causes of secondary trigeminal neuralgia include:

  • Multiple sclerosis, a disease of the nervous system that also damages the myelin sheath.
  • Other diseases that cause inflammation in the body.
  • A brain tumor or a tangle of abnormal veins and arteries that compresses (presses on) the trigeminal nerve.

Sometimes, however, the cause of TN is unknown.

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Symptoms

Symptoms of trigeminal neuralgia may differ depending on the type of TN.

Type 1 TN:

  • Intense flashes of pain set off by stimulus to the face that would normally not be painful (light touch, drinking, shaving, etc.).
  • These “pain attacks” or episodes of pain can happen several times during a day.
  • Pain-free periods that may last months or years, after which the pain might return.
  • Pain is usually located on one side of the face.

Type 2 TN:

  • Constant aching or burning pain that happens in addition to the episodes of “pain attacks.”
  • Pain may be less intense than Type 1 TN.
  • Pain in Type 2 TN is less responsive to surgical treatments.
  • Pain may not be limited to one side of the face.
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Diagnosis

Since pain from TN may be felt in the jaw, cheeks, or mouth, many people may first visit a dentist. A dentist can examine your mouth and teeth for causes of pain. If no dental cause can be found, the dentist may suggest you visit your primary care doctor.

Your doctor will review your medical history and ask about your symptoms, including a detailed description of your pain. He or she may also do a physical examination to test if the sensation in your face and the strength of your chewing muscles are normal.

An orofacial pain specialist, who diagnoses and treats pain in the mouth and face, and/or a neurologist, a specialist in diseases of the nervous system, may also be part of your care team.

A magnetic resonance imaging (MRI) scan of your brain may be done. The MRI can show if a blood vessel is compressing the nerve and how severe the compression is. It can also show if there is a secondary cause of the condition.

Because of the large number of conditions that can cause facial pain, getting a correct diagnosis is sometimes difficult. However, it is important to find the cause of the pain so you can get the right treatment.

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Treatment

Treatment for trigeminal neuralgia starts with medications. When medications are not sufficient to control the pain or when a person cannot tolerate the side effects, surgery may be considered.

Medications

Several medications are available to treat trigeminal neuralgia, which can be used alone or in combination to achieve better pain control.

The table below shows some of the medication classes used to treat TN:

Medications for Trigeminal Neuralgia

Medication Class Examples Important Information
Antiseizure

Carbamazepine

Oxcarbazepine

Phenytoin

Others

 These are usually the first medications the healthcare provider will offer.
Muscle relaxants Baclofen Baclofen is especially helpful in people who have TN secondary to multiple sclerosis.
Antidepressants

Amitriptyline

Nortriptyline

 These tricyclic antidepressants can be used to treat pain.
Neurotoxins Botulinum toxin Type A injections Botulinum toxin Type A injections block the release of substances needed for nerve cells to communicate with each other. Current evidence suggests those injections may help when other medications are not working.

Make sure to ask your healthcare provider if you need to be monitored while taking these medications. Some of these medications require bloodwork on a regular basis to ensure the medications don’t cause unwanted effects in your body.

Surgery

Surgery is considered when medications are not helping, their adverse effects are too severe, or when imaging shows a blood vessel pressing on the nerve.

There are two main types of surgery for TN:

  • controlled lesioning procedures, where the trigeminal nerve fibers are intentionally damaged so pain signals cannot be transmitted, and
  • open surgery, in which the trigeminal nerve is separated from the blood vessel pressing on it.

See the tables below for details.

Surgeries for Trigeminal Neuralgia

Controlled Lesioning Procedures

Name of Procedure How is the lesion created?
Balloon compression With the pressure the balloon applies on the nerve.
Glycerol injection With a thick, colorless liquid called glycerol.
Radiofrequency ablation With heat.
Stereotactic radiosurgery (Gamma Knife, CyberKnife) With radiation.

Balloon compression, glycerol injection, and radiofrequency ablation can be done by inserting a small tube or a needle through the cheek to deliver the treatment. For radiosurgery, a special machine delivers radiation without any cuts or incisions.

Open Surgery

Name of Procedure How is it done?
Microvascular decompression

A surgeon makes a cut (incision) behind your ear.

Then, a small hole is made in the skull to reach the trigeminal nerve and the blood vessel pressing on it.

Finally, a cushion is placed between the blood vessel and the nerve, to relieve the pressure.
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Helpful Tips

If you think you have TN:

  • Visit a doctor to get an accurate diagnosis and discuss treatment options.
  • Take note of the following, which may help the doctor diagnose your condition:
    • What does your pain feel like (examples include: sharp, electric shock like, dull, etc.)?
    • What triggers the pain?
    • Does the pain have a pattern (does it come and go, for example)?
    • Where is the pain located?
    • How long have you had it?
    • Is there something that makes the pain worse (or better)?

Ask questions. Before you decide on a treatment, ask how the treatment will help you, and make sure you understand the risks. Also ask about whether the pain might return after treatment, and what options are available if that happens.

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Additional Resources

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Last Reviewed
June 2022