What is trigeminal neuralgia?
Trigeminal neuralgia (TN), also known as tic douloureux, is a type of chronic pain disorder that involves sudden attacks of severe facial pain. It affects the trigeminal nerve, or the fifth cranial nerve, which provides feeling and nerve signaling to parts of the head and face. Pain attacks typically last only a few seconds (but can last up to two minutes) and may occur over and over again several times a day. TN is a type of neuropathic pain, sometimes caused by an injury or nerve lesion.
Symptoms of TN include:
- Sudden, intense pain, often described as a shock-like or stabbing pain typically on one side of the face
- Burning, throbbing, numbness, tingling, or dull aching sensation in between attacks
The intensity of pain can be physically and emotionally devastating. TN attacks typically stop for a period of time and then return. Pain attacks can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), teeth brushing, nose blowing, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or it may spread. The pain rarely occurs during sleep.
In some cases, the condition can be progressive, meaning that the attacks can get worse over time, with longer and more frequent episodes. In progressive TN, a person may feel pain all the time. In many such cases, medication to control the pain also becomes less effective over time.
TN occurs most often in people over age 50, although it can occur at any age, including infancy. The disorder is more common in women than in men.
What are the trigeminal nerves and how do they work?
The trigeminal nerves are a pair of cranial nerves that connect the brain and brain stem to different parts of the face. The trigeminal nerves have three branches that send and receive sensations from the upper, middle, and lower portions of the face.
- The ophthalmic (upper) branch supplies sensation to most of the scalp, forehead, and front of the head.
- The maxillary (middle) branch supplies sensation to the cheek, upper jaw, top lip, teeth and gums, and side of the nose.
- The mandibular (lower) branch supplies nerves to the lower jaw, teeth and gums, and bottom lip.
More than one nerve branch can be affected by TN, but the maxillary or mandibular branches are the most commonly affected. When the ophthalmic branch is affected, redness or unexplained tears in the eyes may also occur at the same time as pain attacks. In rare cases, both sides of the face may be affected at different times, or even at the same time; this is called bilateral TN.
Types of trigeminal neuralgia
Types of trigeminal neuralgia are categorized based on the cause:
Classic: This is the most common form, in which a blood vessel (usually the superior cerebellar artery) is found to be pushing on part of the trigeminal nerve root.
Secondary: In these cases, TN is caused by another disorder (such as multiple sclerosis, a tumor, or arteriovenous malformation). Individuals with secondary TN are more likely to be younger and to have pain on both sides of the face. Only 15% of TN cases are secondary.
When no clear cause can be found even after a diagnostic workup (evaluation), it is considered idiopathic TN. This is the least common type of TN.
How is trigeminal neuralgia diagnosed and treated?
Diagnosing trigeminal neuralgia
A healthcare provider will conduct a physical examination, review the person’s full medical history, and consider their symptoms when diagnosing TN. A workup usually includes a neurological examination and imaging with MRI (magnetic resonance imaging) to look for structural abnormalities (such as compression of the trigeminal nerve) or other disorders that could cause facial pain.
Treating trigeminal neuralgia
Generally, the first line of treatment for people living with TN is medication. If medication is unable to relieve pain or produces intolerable side effects, surgery may be considered. In some cases, complementary approaches, usually combined with medications, may help manage TN.
Medications for trigeminal neuralgia
There are several types of medication that can help treat TN:
- Anticonvulsant medicines, which are used to block pain signals, can reduce the frequency of attacks. These drugs include carbamazepine, oxcarbazepine, gabapentin, pregabalin, lamotrigine, topiramate, or phenytoin. If a single drug fails to improve symptoms, more than one drug may be used at the same time.
- Other medications may be tried, particularly if anticonvulsants are not effective or side effects are too bothersome. These drugs include baclofen and Botulinum toxin A.
Common pain-relieving medications (such as aspirin and ibuprofen) and opioid medications such as hydrocodone are not usually helpful in treating TN.
Surgery for trigeminal neuralgia
If medication fails to relieve pain or produces intolerable side effects such as cognitive disturbances, memory loss, excess fatigue, bone marrow suppression, or allergy, the doctor may recommend surgical treatment. Since TN can be a progressive disorder that becomes resistant to medication over time, surgery is a common approach to reducing the risk of future attacks of pain.
Several neurosurgical procedures are available to treat TN. The choice of procedure depends on:
- The nature of the pain
- The person’s preference, physical health, blood pressure, and previous surgeries
- The presence or absence of multiple sclerosis
- Which trigeminal nerve is most affected (particularly when the upper/ophthalmic branch is involved)
Facial numbness may occur after many of these procedures, and TN will often return even if the procedure is initially successful. As with any surgery, there are risks to the surgical procedures used to treat TN. Depending on the procedure, these include hearing loss, balance problems, leaking of the cerebrospinal fluid, infection, anesthesia dolorosa (persistent intense pain in the face or mouth), and (in rare cases) stroke.
Some surgeries to address TN are done on an outpatient basis, while others may involve a more complex operation that is performed under general anesthesia and requires a hospital stay.
Microvascular decompression (MVD) is the most invasive surgery for TN. It is also the most effective at preventing pain long-term. MVD involves relieving pressure from surrounding blood vessels that either wrap the nerve or are touching it. Unlike rhizotomies (described below), the goal is not to produce numbness in the face after this surgery.
Rhizotomy (rhizolysis) is a procedure in which nerve fibers are damaged in order to block pain. People who use a rhizotomy for TN always experience some degree of sensory loss and facial numbness. There are several different forms of rhizotomy used to treat TN, including balloon compression, glycerol injection, radiofrequency thermal lesioning, and stereotactic radiosurgery. These surgeries may relieve pain for a few years but are less effective long term.
Radiosurgery is a procedure that aims focused radiation on damaged nerve fibers from the trigeminal nerve close to where it is connected to the brainstem. Unlike other surgical procedures, pain relief resulting from this procedure may take over a month to develop.
Complementary treatments for trigeminal neuralgia
Some people manage TN using complementary approaches, usually in combination with medications. These therapies have varying degrees of success. Complementary treatments include:
- Low-impact exercise
- Creative visualization
- Chiropractic treatment of upper spine
- Vitamin therapy
- Nutritional therapy
What are the latest updates on trigeminal neuralgia?
NINDS, a part of the National Institutes of Health (NIH), supports a variety of research on TN. These studies explore the mechanisms involved with chronic pain and TN, as well as novel diagnostic methods and treatments. Other research addresses TN through studies associated with pain research. The National Institute of Dental and Craniofacial Research, another component of NIH, also funds TN and neuropathic pain research.
NINDS-supported scientists are studying changes that occur in the trigeminal nerve in response to injury to learn more about the cause of neuropathic pain with the goal of developing more effective therapies for TN and other neuropathic pain disorders. Other researchers are looking at non-opioid treatments such as immunomodulatory therapy to treat neuropathic pain. Immunotherapy works by altering the body’s immune response.
More information about TN and facial pain research supported by NINDS and other NIH Institutes and Centers can be found using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies. RePORTER also includes links to publications and resources from these projects.
How can I or my loved one help improve care for people with trigeminal neuralgia?
Consider participating in a clinical trial so clinicians and scientists can learn more about TN and facial pain. Clinical research uses study participants to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.
All types of participants are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.
Where can I find more information about trigeminal neuralgia?
Information may be available from the following organizations:
Facial Pain Association (formerly the Trigeminal Neuralgia Association)
Phone: 352-384-3600 or 800-923-3608
Facial Pain Research Foundation
National Institute of Dental and Craniofacial Research (NIDCR)