Trigeminal Neuralgia (Facial Nerve Pain)

The trigeminal nerve is a cranial nerve (meaning it exits the brain through the skull, bypassing the spinal cord). The trigeminal nerve provides sensation and control of the face. Inflammation of or pressure on the trigeminal nerve can cause intense pain, sometimes requiring surgery.

Trigeminal neuralgia causes facial pain. Trigeminal neuralgia develops in mid to late life. The condition is the most frequently occurring of all the nerve pain disorders. The pain, which comes and goes, feels like bursts of sharp, stabbing, electric-shocks. This pain can last from a few seconds to a few minutes.

People with trigeminal neuralgia become plagued by intermittent severe pain that interferes with common daily activities such as eating and sleep. They live in fear of unpredictable painful attacks, which leads to sleep deprivation and undereating. The condition can lead to irritability, severe anticipatory anxiety and depression, and life-threatening malnutrition. Suicidal depression is not uncommon.

People often call trigeminal neuralgia "tic douloureux" because of a characteristic muscle spasm that accompanies the pain.

• The pain comes from one or more branches of the trigeminal nerve-the major carrier of sensory information from the face to the brain.
  • There are 3 branches of the trigeminal nerve: the ophthalmic, maxillary, and mandibular. The pain of trigeminal neuralgia occurs almost exclusively in the maxillary and mandibular divisions.
  • You most commonly feel pain in the maxillary nerve, which runs along your cheekbone, most of your nose, upper lip, and upper teeth. Next most commonly affected is the mandibular nerve, affecting your lower cheek, lower lip, and jaw.
• In almost all cases, pain will be restricted to one side of your face.
• Most of the time, doctors cannot identify any disease of the trigeminal nerve or the central nervous system.
• Trigeminal neuralgia most frequently affects women older than 50 years. The disease occurs rarely in those younger than 30 years. Such cases are usually linked to damage from diseases of central nervous system, for example, multiple sclerosis.

• The condition has no clear-cut cause.
  • Some experts argue that the syndrome is caused by traumatic damage to the nerve as it passes from the openings in the skull to the muscles and tissue of the face. The damage compresses the nerve, causing the nerve cell to shed the protective and conductive coating (demyelination).
  • Others believe the cause stems from biochemical change in the nerve tissue itself.
  • A more recent notion is that an abnormal blood vessel compresses the nerve as it exits from the brain itself.
• In all cases, though, an excessive burst of nervous activity from a damaged nerve causes the painful attacks.

• A defining feature of trigeminal neuralgia is the trigger zone-a small area in the central part of the face, usually on a cheek, nose, or lip, that, when stimulated, triggers a typical burst of pain.
  • A light touch or vibration is the most effective trigger.
  • Because of this, many common daily activities trigger the attacks.
    • Washing your face, brushing your teeth, shaving, or talking
    • Common sensations such as having wind hit your face
    • Eating and chewing
• Many people avoid food and drink rather than experience the severe pain.
  • These people risk weight loss and dehydration, a leading cause of hospitalization in this group.
  • People frequently require hospitalization for rapid pain control when their trigeminal neuralgia becomes unmanageable at home.
• Between attacks, most people remain relatively pain-free. A subgroup, however, experience a dull ache between attacks, suggesting physical compression of the affected nerve, either by a blood vessel or some other structure.

Contact your doctor when you begin to have these pains.

• It is essential you see a doctor familiar with the care of patients with trigeminal neuralgia early on to help prevent the development of more severe complications.
• It is especially important to work with your doctor because with appropriate drug therapy trigeminal neuralgia can almost always be controlled.

Seek immediate medical attention or go to a hospital's Emergency Department under the following circumstances:

• When your current medication does not control the pain and you need immediate relief
• When your pain prevents eating and drinking and places you at risk for malnutrition or dehydration
• When you experience profound side effects of your medication such as severe drowsiness, sedation, nausea, or vomiting
• When a doctor advises you to seek evaluation and treatment for any of these problems

Your doctor must rule out a variety of other causes of facial pain besides trigeminal neuralgia, including various unusual forms of headache.

• Atypical neuralgia
• Myofascial pain
• Temporomandibular facial pain
• Cluster headaches
• Local disease in the sinuses, jaw, throat, and bones of your head
  • Physical examination of the head will help define other possible causes of this painful syndrome. Physical findings in people with trigeminal neuralgia are normal.
  • A doctor should complete an initial neurological examination to determine the presence of other conditions, such as multiple sclerosis, that are associated with nerve pain syndromes like trigeminal neuralgia.
  • Doctors reserve more extensive testing, such as a CT scan or MRI of the head, for people in whom they suspect an associated condition, such as skull or brain tumor, infection, or neurological condition.

Because the pain stems from nerves deep inside your skull, no home remedy is effective.

Trigeminal neuralgia is extremely painful but not life threatening. Thus, a goal of therapy is minimizing dangerous side effects.

Medications used to treat trigeminal neuralgia are those used for many other nerve pain syndromes-drugs originally designed to treat seizures.

These antiseizure agents suppress excessive nerve tissue activity, which is the cause of the painful syndrome. As a result, they are useful in conditions such as trigeminal neuralgia.

Pain specialists use invasive therapy, including nerve blocks, nerve destruction, and nerve decompression techniques, as well as drug therapy to treat trigeminal neuralgia.

• In some instances, a single injection, or a series of injections, or perhaps one decompressive procedure, will reduce or eliminate the pain and prevent your need for a long course of drug therapy.
• Injection techniques also can relieve unremitting pain instantly and further confirm the diagnosis.
• Using real-time X-rays, doctors can target the anatomical origin of the nerve deep in your skull. Then, with a fine needle, they can do one of the following to halt the painful syndrome:
  • Inject that source with anesthetic and steroid.
  • Inject that nerve with a drug used to destroy faulty cells.
  • This procedure can be performed with surprisingly little discomfort.

Doctors use 3 main drugs to treat trigeminal neuralgia-baclofen (Lioresal), carbamazepine (Tegretol), and phenytoin (Dilantin).

• Baclofen is the safest of the 3, though less effective. Many doctors begin therapy with baclofen and monitor its results over a week's time.
• For years, carbamazepine had been the mainstay for treating this disorder. In fact, many experts believe that if you get no relief from 2 days of carbamazepine treatment, doctors must reconsider the diagnosis of trigeminal neuralgia.
  • The side effects of this drug include dizziness, sedation, confusion, and rash.
  • The doctor likely will complete a series of blood and urine tests before beginning treatment to establish a baseline of laboratory values.
  • Carbamazepine in unusual instances causes a rare blood disease known as aplastic anemia.
  • Frequent blood monitoring avoids this problem. You can expect to take consistent doses of this medicine for about 6 months before your doctor reconsiders the dosing schedule.

If doctors clearly determine the cause of the disorder to be compression of an artery on the trigeminal nerve deep in your skull, a neurosurgeon can perform a microvascular decompression.

• The surgeon moves the compressing artery to a location away from the compressed root of the nerve.
• The major disadvantage is that it requires a neurosurgical operation-with all its complications-to get access to the root of the trigeminal nerve.

Doctors do not know how to prevent trigeminal neuralgia, to predict who will get it, or determine who will respond to a particular treatment until it is tried.

Clearly, though, the overwhelming majority responds to at least one of the treatments and can obtain excellent benefit from it.

More and more people find substantial relief from invasive treatment, either anesthetic injections or decompressive therapy. It is very rare that someone with trigeminal neuralgia does not obtain long-standing relief.