Trigeminal Neuralgia

What is Trigeminal Neuralgia?

Trigeminal neuralgia (TN), also known as tic douloureux, causes intense attacks of facial pain that can interfere with daily activities. It is often triggered when a blood vessel compresses the trigeminal nerve (the nerve responsible for sensation in the face and head) near the brainstem. TN is typically considered a form of neuropathic pain.

Although trigeminal neuralgia is not life-threatening, it can significantly impact your quality of life. Everyday actions such as talking, chewing, smiling, and brushing your teeth can trigger sudden, brief episodes of severe pain, making TN both a physical and emotional challenge.

TN is usually chronic, but a range of treatments can help manage symptoms.

Symptoms

The main symptom of trigeminal neuralgia is sudden, extreme facial pain, often on one side of the face. This pain is often described as a sharp, electric shock-like sensation. During these episodes, you may experience muscle spasms in the face. Between painful episodes, some people may experience other sensations, such as:

• Burning
• Numbness
• Throbbing
• Dull aching

Trigeminal neuralgia can be classified into two primary types based on symptom presentation:

• Paroxysmal TN: Characterised by severe, intermittent painful attacks. You may experience a burning sensation or discomfort in the face, lasting from a few seconds to two minutes, or in some cases, up to two hours, with pain-free intervals between attacks.
• TN with constant pain: Involves more frequent, less intense pain. This may feel like a constant burning or stabbing sensation. Atypical trigeminal neuralgia can be more challenging to manage.

TN typically affects one side of the face (unilateral), though it can occur on both sides (bilateral), though not simultaneously. Over time, TN can worsen, resulting in longer and more frequent bouts of pain.

Triggers of Trigeminal Neuralgia

Simple activities involving facial movement or touch can trigger TN pain, including:

• Shaving, applying makeup, or washing your face
• Eating and drinking
• Talking or smiling
• Brushing teeth, flossing, or using mouthwash
• Touching the face, particularly around the jawline or cheek
• Feeling a slight gust of wind or breeze on the face

It is rare for pain episodes to occur during sleep.

Causes

Trigeminal neuralgia is typically caused by damage or pressure on the trigeminal nerve. The condition is classified based on the underlying cause, including:

• Primary (classic) TN: The most common cause, occurring when a blood vessel, usually the superior cerebellar artery, compresses part of the trigeminal nerve root.
• Secondary TN: This occurs when another medical condition, such as a tumour, arteriovenous malformations, or multiple sclerosis (MS), affects or damages the trigeminal nerve. Secondary TN is more common in younger individuals and is often bilateral, affecting both sides of the face. Approximately 15% of TN cases fall into this category.
• Idiopathic TN: When no clear cause can be identified following tests, the condition is considered idiopathic TN.

Risk Factors

Factors that increase the likelihood of developing trigeminal neuralgia include:

• High blood pressure
• Ageing
• Smoking
• Being female
• Family history of the condition

Tests and Diagnosis

How do healthcare providers diagnose TN?

To diagnose trigeminal neuralgia, your healthcare provider will ask about your symptoms and medical history, followed by a neurological exam and physical examination of your head and neck.

The diagnosis is based on several factors, including:

• The type of pain you experience
• The specific location of the pain on your face
• The activities that trigger the pain

Facial pain can be a symptom of various conditions, including migraines, cluster headaches, TMJ dysfunction, and postherpetic neuralgia, so your doctor will need to rule out these other disorders first. To identify the exact cause of TN, such as nerve compression from a tumour or blood vessel, an MRI scan of the brain may be recommended.

Management and Treatment

How is trigeminal neuralgia treated?

Treatment for trigeminal neuralgia usually involves a combination of medication, surgery, and alternative therapies. However, finding the most effective treatment approach may take time.

Medication for TN

Medication is often the first line of treatment for primary (classic) and idiopathic TN. Commonly prescribed drugs include:

• Anti-seizure medications: These work by reducing pain impulses. Carbamazepine or oxcarbazepine is often prescribed initially to manage pain, though effectiveness may decrease over time. Other medications include pregabalin, gabapentin, lamotrigine, topiramate, lacosamide, and phenytoin.
• Baclofen: A muscle relaxant sometimes prescribed to manage pain.

Each medication comes with potential side effects, so you will work closely with your healthcare provider to find the best treatment for your condition.

Surgical Options for TN

Surgery may be considered when medications fail to control symptoms or if secondary TN, such as a tumour pressing on the nerve, is diagnosed. Surgical procedures vary in complexity and carry different risks. Your doctor will discuss these options with you in detail.

Surgical options include:

• Microvascular decompression: A procedure to relieve pressure on the trigeminal nerve caused by a blood vessel. While this is the most invasive TN surgery, it is also highly effective for long-term pain relief.
• Radiosurgery: Radiation is directed at the trigeminal nerve root to block pain impulses. Relief may take more than a month.
• Rhizotomy: This procedure involves intentionally damaging the trigeminal nerve to block pain. Techniques include mechanical balloon compression, chemical injection, or thermocoagulation. Rhizotomy may cause numbness and sensory loss in the face, and pain relief is usually temporary, lasting only a few years.
• Peripheral neurectomy: Involves removing or damaging the peripheral branch of the trigeminal nerve. This can be done via incision, alcohol injection, radiofrequency lesioning, or cryotherapy.

Additional Treatments for TN

In addition to medication, healthcare providers may recommend:

• Botulinum toxin injections or nerve blocks for short-term pain relief
• Biofeedback
• Acupuncture
• Psychotherapy
• Meditation
• Yoga
• Aromatherapy

Outlook / Prognosis

What should I expect if I have TN?

TN affects each individual differently. Some experience clusters of attacks lasting for weeks or months, followed by pain-free periods, while others have constant background pain with painful episodes. Over time, TN may worsen, and medications can become less effective.

Regular follow-up appointments with your doctor are important to monitor your condition and ensure treatment is working. You don’t have to live with chronic pain without seeking help.

Possible Complications of TN

The intense pain caused by TN can impact mental health and daily life. People with TN may be at risk of depression, anxiety, and social isolation.

Seeking professional support is crucial if TN affects your mental well-being. Contact a healthcare provider or mental health specialist, such as a psychologist, for assistance.

Additionally, prolonged use of anti-seizure medications can lead to conditions such as osteoporosis, while some surgical procedures may result in permanent facial numbness.

Living With TN

When should I consult a doctor?

You should consult a healthcare provider immediately if you experience severe facial pain. People with TN should see their doctor regularly to ensure that treatments remain effective.

What questions should I ask my healthcare provider?

When discussing TN with your healthcare provider, consider asking:

• What caused my trigeminal neuralgia?
• What type of TN do I have?
• How can I reduce pain during facial movements?
• What treatment options are available for my condition?
• What are the pros and cons of my recommended treatment?
• Are there support groups for people with TN?

A Note from MD.co.uk

While trigeminal neuralgia is primarily a physical condition, it can also affect your emotional and mental well-being. The fear of triggering severe pain may lead to social withdrawal or anxiety about everyday activities. Fortunately, there are treatments available to help you regain control of your life and enjoy it to the fullest, even if you may live with TN in some form for many years.