Recognizing Trigeminal Neuralgia and Facial Pain—Pain Attacks and the Treatment of Facial Pain

The trigeminal nerve transmits sensory stimuli from the face to the brain. Another function of the nerve is to control the masticatory and temporal muscles.

If the trigeminal nerve is irritated, stimulated, or damaged, severe pain results. This can happen, for example, when the nerve becomes pinched. Common causes include nearby blood vessels that exert pressure on the cranial nerve. A facial injury can also cause one of the nerve branches to become pinched.

The resulting symptoms can severely disrupt a patient’s daily routine. The course of facial pain cannot be predicted in advance: Some patients remain symptom-free for weeks or months. Others, however, report that pain attacks become more frequent as the condition progresses.

The likelihood of developing the extremely painful condition known as trigeminal neuralgia increases with age. Nevertheless, this form of facial pain is relatively rare: each year, about 4 out of every 100,000 people develop trigeminal neuralgia.

Branches of the trigeminal nerve in the face © Henrie | AdobeStock

Trigeminal neuralgia occurs in attacks: sudden, very severe, and stabbing pain often confined to one side of the face. An attack lasts from a few seconds to a maximum of two minutes. Even the teeth and the nasolabial folds can be affected. The nasolabial folds run from the nose to the mouth.

Such attacks can occur several times a day. For most patients, the time between facial pain attacks is symptom-free. However, some complain of constant pain in the facial area.

The pain is sometimes accompanied by reflex-like muscle spasms in the affected half of the face. For this reason, this debilitating condition is also known as tic douloureux.

Because the pain attacks are very severe and emotionally distressing, many patients also suffer from depression. Out of fear of the next attack, many of them even skip daily meals and lose weight.

People experiencing these symptoms should contact their doctor immediately.

The International Headache Society (IHS) distinguishes between classic and symptomatic trigeminal neuralgia in this very rare condition.

The exact cause of the classic form has not yet been medically determined. Triggers can include, for example,

• a simple draft,
• chewing movements,
• speaking,
• brushing one’s teeth, or
• psychological stress

are possible causes.

Symptomatic trigeminal neuralgia occurs as a symptom of an underlying condition. Examples include:

• multiple sclerosis
• a brain tumor
• a stroke
• a vascular malformation
• a traumatic brain injury (head injury)

Patients with symptomatic facial pain do not experience pain-free episodes. The pain always occurs on both sides.

The diagnosis is made by the primary care physician, as the patient usually consults him or her first. The neurologist (a doctor specializing in nervous system disorders) then examines the patient for any underlying conditions.

Typically, the neurologist orders a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan. These imaging procedures are used to identify any abnormal findings, such as a brain tumor.

If the doctor suspects that multiple sclerosis is the cause of the stabbing facial pain, they perform a lumbar puncture: They withdraw a small amount of cerebrospinal fluid (CSF) from the spinal canal and have it analyzed in the laboratory. In addition, the doctor will perform blood tests to rule out other possible diagnoses.

With the help of MR angiography, the specialist can create a detailed image of the blood vessels. This allows them to check, for example, whether there are any malformed blood vessels.

If surgery is necessary, the neurosurgeon can use the images to identify the exact course of the blood vessels in the surgical area.

Treatment of Classic Trigeminal Neuralgia

For the classic form of trigeminal neuralgia without an underlying condition, the doctor usually prescribes medication. These are not painkillers, which are ineffective in acute cases. Instead, the condition is treated with anti-epileptic drugs. These drugs block nerve impulses before they reach the brain.

The specialist often prescribes medications containing the active ingredient carbamazepine. The patient takes them in progressively higher doses until relief is achieved. Alternatively, oxcarbazepine and baclofen may be used. This reduces the hyperexcitability of the fifth cranial nerve.

If the pain is too severe, the patient must take both medications at the same time. In the hospital, the antiepileptic drug phenytoin is administered as part of the treatment.

Surgery is the treatment of choice for this condition only if

• the medications are not effective,
• they cause severe side effects, or
• the patient has, for example, a tumor.

The neurosurgeon then uses one of three surgical procedures.

He blocks the activity of the nerve clusters using radiosurgery. In this procedure, a high dose of radiation is precisely directed at the surgical site (CyberKnife procedure). The radiation destroys the nerve fibers near the brainstem. Most patients are symptom-free as early as one day after treatment. In some cases, however, it takes two weeks to a maximum of two months for the patient to be relieved of their facial pain.

Thermocoagulation is another option. In this method, extreme heat destroys the nerve fibers. If a blood vessel is pressing on the trigeminal nerve, there is an additional treatment option. The doctor inserts a small sponge between the blood vessel and the nerve.

Treatment of Symptomatic Trigeminal Neuralgia

Symptomatic trigeminal neuralgia primarily affects younger people. Treatment depends on the underlying condition.

If the intense pain leads to depression, patients may also require additional psychological support.

Risks of trigeminal nerve surgery

Today’s surgical methods are well-established and utilize state-of-the-art technology. Furthermore, neurosurgeons are highly qualified and experienced. Nevertheless, surgical procedures on the trigeminal nerve can result in permanent health complications.

These include, for example

• hearing problems,
• sensory disturbances in the face (numbness in the facial skin), and
• visual disturbances.

Furthermore, despite surgery, relapses can generally occur from time to time.

For severe nerve pain, a neurologist is the right person to consult. A neurologist is an expert in disorders of the nervous system.

Neurologists are physicians who, after completing medical school, undergo 60 months of specialized training in neurology and psychiatry.

A neurosurgeon can also be an expert in trigeminal neuralgia. Their area of expertise includes surgical procedures involving the nervous system.

What is trigeminal neuralgia?

Trigeminal neuralgia is a disorder of the trigeminal nerve. It is typically characterized by sudden, shooting facial pain that occurs in attacks. Classic trigeminal neuralgia is often caused by a neurovascular contact with a blood vessel near the brainstem.

What are the symptoms of trigeminal neuralgia?

The most important symptom is sudden, acute episodes of facial pain. The pain is often described as lightning-like, shooting, or electric and can be triggered by chewing, brushing teeth, or touching the face. Some people remain pain-free between attack episodes.

What causes trigeminal neuralgia?

In idiopathic trigeminal neuralgia, a blood vessel usually presses on the trigeminal nerve. Symptomatic trigeminal neuralgia, on the other hand, can result from multiple sclerosis, a tumor, or other neurological conditions. There are therefore different forms of trigeminal neuralgia.

How is trigeminal neuralgia treated?

Treatment for trigeminal neuralgia usually begins with medication, specifically carbamazepine. If side effects occur or medication fails, treatment options such as thermocoagulation, radiosurgery, or neurosurgery may be considered. Jannetta microvascular decompression, which involves placing a Teflon shim between the nerve and the blood vessel, is particularly successful.

How is the condition diagnosed?

The diagnosis is made clinically through a neurological examination and an MRI of the brain. These tests assess whether there is vessel-nerve contact, a symptomatic cause, or changes in the ganglion of Gasser. Diagnosis and treatment should be initiated early to prevent long-term impairments to quality of life.