Trigeminal Neuralgia: Causes, Symptoms, Treatment & Surgery

In this article, we will learn everything about trigeminal neuralgia including its types, causes, symptoms, risk factors, diagnosis, prevention, triggers, treatment, surgery, complications, etc.

What is Trigeminal Neuralgia (TN)?

Trigeminal neuralgia is a chronic pain condition that typically affects the fifth cranial (or trigeminal) nerve and is characterized by recurrent brief episodes of electric shock-like pain.

It is also known as neuropathic facial pain, tic douloureux (meaning painful tic), prosopalgia, Trifacial Neuralgia, Suicide Disease, or Fothergill’s disease. The condition is usually trigeminal nerve related but it can be attributed to many other factors that are not necessarily nerve related.

There are two separate trigeminal nerves, one on each side of the face. These nerves are responsible for carrying the sensory supply of the face and the motor and sensory supply to the muscles of mastication.

The pain can be triggered by certain activities such as eating or brushing. It is possible to have Trigeminal neuralgia (TN) of any (or all) branches of the trigeminal nerve. Typically the pain occurs at one side of the face and in rare cases, it affects both sides.

Trigeminal neuralgia pain can be felt anywhere in the face, depending on which branch and which part of the trigeminal nerve is irritated. Mostly, it is felt in the lower face and jaw, while sometimes it affects the area above the eye and around the nose.

Remarkably, the right side of the face is usually more affected by this condition than the left.

It affects women more often than men and is more likely to occur in people who are older than 50.

The triggers can vary widely between patients. The severity and frequency of attacks can also vary widely, making trigeminal neuralgia difficult to treat effectively.

The disease can strike at any age and is considered one of the most painful diseases known to humanity.

What is the Trigeminal nerve?

There are 12 pairs of cranial nerves and the trigeminal nerve is the fifth one of these 12 pairs. It is also called the cranial nerve V. It’s responsible for sending pain, touch, and temperature sensations from your face to your brain.

You have two trigeminal nerves, one on each side of your body. Each trigeminal nerve starts at the pons and divides into three branches, all of which are responsible for transmitting nerve impulses to different parts of your face.

Branches of the Trigeminal nerve are:

The Ophthalmic Branch (V1)

It supplies the forehead, eye, and upper eyelid.

The Maxillary Branch (V2)

It supplies the cheek, upper lip, nostril, lower eyelid, and upper gum.

The Mandibular Branch (V3)

It supplies the lower gum, lower lip, jaw, and muscles of mastication.

What Are The Types of Trigeminal Neuralgia?

There are two main types of trigeminal neuralgia:

• Typical (Type 1) trigeminal neuralgia

• Atypical (Type 2) trigeminal neuralgia

Typical (Type 1) trigeminal Neuralgia

In Typical (Type 1) trigeminal neuralgia:

• You may experience painful episodes that are intense, sharp, and sporadic.

• Pain is present all over the face that can last anywhere from a few seconds to two minutes.

• In between episodes, pain-free breaks are present that can continue for up to two hours.

• The pain usually affects one side of the face

Atypical (Type 2) trigeminal Neuralgia

Atypical (Type 2) trigeminal neuralgia:

• Is less painful and intense but more widespread.

• In this type, pain is constant, and is aching or burning rather than stabbing or shocking pain

• You may have more difficulty controlling the symptoms.

• The pain is usually less severe than the typical trigeminal neuralgia.

Difference Between Both Types of Trigeminal Neuralgia

What Are The Causes of Trigeminal Neuralgia?

The cause of trigeminal neuralgia is not clear yet. But it is said to be caused when the trigeminal nerve is compressed or affected due to other medical conditions. The trigeminal nerve also known as the 5th cranial nerve is present on each side of the face. These nerves are necessary to provide sensation to the face. There are 2 types of Trigeminal neuralgia which are primary TN and secondary TN. Both are caused by different reasons.

The primary TN is caused when the trigeminal nerve is pressed, usually in the base of the head where the brain meets the spinal cord. According to researchers, it is the reason for Trigeminal neuralgia in 95% of cases.

Mostly, the cause of this compression is due to contact between a healthy vein or artery and the trigeminal nerve at the base of the brain, and this places pressure on the nerve when it enters the brain.

There is no clear evidence that this pressure becomes the reason for attacks with pain in some persons but not in others. It is not necessary that everyone with such pressure on the trigeminal nerve gets pain.

Whereas secondary TN refers to when Trigeminal neuralgia is caused by some other medical condition.

These conditions may include:

• Damage occurring due to surgery such as dental surgery

• Facial injury

• Multiple sclerosis (MS) (a condition that damages the myelin sheath)

• Arteriovenous malformation,

• A cyst which is a fluid-filled sac,

• A tumor

There are some cases of trigeminal neuralgia which do not have any specific cause and are known as Idiopathic Trigeminal Neuralgia (TN).

What Are The Symptoms of Trigeminal Neuralgia?

The symptoms of Trigeminal Neuralgia may include one or more of the following symptoms:

1) The episodes of severe jabbing or shooting pain that may feel like an electric shock

2) Severe attacks of severe, shooting pain in the face that last between seconds to several minutes

3) Spontaneous attacks of pain or attacks which get triggered by certain activities like brushing teeth, speaking, chewing, touching the face, etc.

4) Attacks of pain that become more frequent and intensify with time

5) Pain focused in one area or spread in a wider pattern

6) Pain that affects one side of the face at a time

7) Areas supplied by the trigeminal nerves such as lips, gums, teeth, jaw, cheek, and even forehead and eyes are affected by the pain.

8) Regular episodes of facial pain lasting days, weeks, months, or longer at a time, which may disappear and not return for months or years

9) Pain that rarely occurs at night while sleeping

10) A burning sensation or slight ache after the most severe pain has subsided

11) Pain that occurs with facial spasms

What Are The Risk Factors For Trigeminal Neuralgia?

Although trigeminal neuralgia can occur in any person at any time of life, certain conditions increase the risk of trigeminal neuralgia, these risk factors include:

Gender

Women are most likely to get trigeminal neuralgia as compared to men.

Age

People more than 50 years of age are higher at risk of getting this illness.

Hypertension

High BP or hypertension is also considered the risk factor for trigeminal neuralgia.

Surgery on sinuses and improper or excessive dental work

Surgery on sinuses and improper or excessive dental work also can increase the risk.

Injury

Any injury or blow to the face is also a risk factor for trigeminal neuralgia.

Certain Health Conditions

There are some conditions that lead to the pressure on the trigeminal nerve and these include multiple sclerosis, arteriovenous malformation, an aneurysm, a tumor, etc.

How to Diagnose Trigeminal Neuralgia?

The diagnosis of trigeminal neuralgia is done on the basis of certain factors such as symptoms, medical history, etc. Also, the healthcare provider will perform the physical examination of teeth, mouth, ears, temporomandibular joint (TMJ), and other parts of the head and neck. Majorly the diagnosis of Trigeminal neuralgia is based on your description of the pain, such as:

• Type of pain

• Location i.e. the area of the face that has pain, and

• The activities which trigger the pain or pain attack.

The doctor will need and ask for all these descriptions in order to diagnose your trigeminal neuralgia.

Well, facial pain might be a symptom of many other health conditions. So it is important to determine if there is any other disorder or health condition which is mimicking trigeminal neuralgia. Such conditions include:

• TMJ (temporomandibular joint) disorder

• Post-herpetic neuralgia (pain following an outbreak of shingles)

• Migraines

• Cluster headaches

Your doctor will also rule out ear infections and sinusitis.

To rule out the exact cause of the symptoms, the doctor will perform certain examinations or tests. These include:

Neurological Examination      

Your doctor may perform a neurological examination which helps to determine the functioning of nerves in your brain and your motor system. They will also assess your reflexes and capacity to tolerate pain.

Magnetic Resonance Imaging (MRI)  

MRI or magnetic resonance imaging scan of your head will help to rule out whether a brain tumor or multiple sclerosis is responsible for causing trigeminal neuralgia. In certain cases, the doctor may inject a dye into a blood vessel to view whether there’s a blood vessel pressing on the trigeminal nerve.

Prevention of Trigeminal Neuralgia

Unfortunately, there are currently no guidelines on preventing the development of trigeminal neuralgia.

But, people who already have the condition can prevent painful attacks by avoiding certain activities that cause severe, intense pain. These include:

• Avoid washing your face with too cold or too hot water, always use warm water for this purpose.

• Try to consume only soft foods

• Avoid too hot or too cold food items; try to consume foods that are warm, cool, or at room temperature

• Some food items such as citrus fruits, caffeine, etc. may trigger pain attacks. So, avoid the consumption of these food items.

• Gently brush your teeth and always use a soft bristle brush for that.

• Whenever you eat, rinse your mouth only with water at room temperature.

• Cover your face with a scarf to protect it from wind, if wind triggers your pain.

• Avoid doing any known activities that you know have caused pain in the past.

Triggers of Trigeminal Neuralgia

Pains or attacks of trigeminal neuralgia might get triggered by certain activities which include:

• Talking

• Smiling

• Putting on makeup

• When a strong gust of wind or a breeze blows over your face

• Consuming cold or hot foods or beverages

• Eating

• Drinking

• Blowing your nose

• Brushing your teeth

• Flossing

• Shaving

• Washing your face

• Gently touching your face

• Applying any pressure to your face, particularly to your jawline or cheek

Some additional mimickers of trigeminal neuralgia include temporomandibular joint syndrome (TMJ), ear infection, sinus infection, glossopharyngeal neuralgia, post-herpetic neuralgia, dental pain, giant cell arteritis, occipital neuralgia, Ernest syndrome, and temporal tendinitis.

What Are the Available Treatment For Trigeminal Neuralgia?

In most cases, medications are enough to treat trigeminal neuralgia and people don’t require any other treatment. But in some cases, there is a need for some additional treatment such as injections or surgery as the person doesn’t respond to medication as required.

If another cause, like multiple sclerosis, is the reason for your condition, then your doctor will treat the underlying condition.

Medications For Trigeminal Neuralgia

Usually, for the treatment of trigeminal neuralgia, your doctor will prescribe medications to reduce or block the pain signals sent to your brain. These are:

Anticonvulsant Drugs

These drugs are used to treat and get relief from pain caused by trigeminal neuralgia. Usually, Carbamazepine is the first choice for treating the pain associated with this condition. Some other medicines prescribed by your healthcare provider in this category include topiramate, clonazepam, gabapentin, sodium valproate, lamotrigine, phenytoin, and oxcarbazepine.

It is a possibility that over time these medications may become less effective. In such cases, your health care provider will either increase the dose or change the type of drug.

There are some side effects of using these medications such as:

• Nausea

• Drowsiness

• Confusion

• Dizziness

A serious drug reaction is also possible in the case of Carbamazepine (mainly those of Asian descent). Thus, genetic testing may be suggested before starting carbamazepine.

Tricyclic Antidepressants

These drugs are used for the treatment of symptoms of Type 2 trigeminal neuralgia (Type 2 TN). The typical medicines used under this category are nortriptyline or amitriptyline.

Muscle Relaxants (or Antispasticity Agents)

Antispasticity agents are also known as muscle relaxants and are used as muscle relaxing agents. The most common drug used in this category is Baclofen. One can use Baclofen as a single prescribed medication or can also be used it by combining it with phenytoin or carbamazepine.

The common side effects of these drugs include

• Drowsiness

• Nausea

• Confusion

Botox Injections

People with trigeminal neuralgia who do not get relief from medications may be given Botox (onabotulinumtoxinA) injections. It may provide temporary relief from pain.

Though, more research is required before widely using this treatment for trigeminal neuralgia.

Surgery For Trigeminal Neuralgia (TN)

In case your body doesn’t respond to the drugs or medications, or your condition keeps on worsening, then there might be a need for surgery.

There are many available options when it comes to surgery. Your doctor will suggest you the most suitable one depending on certain factors, such as:

• Physical health (whether you have any other medical condition)

• Severity of pain

• Any previous surgery

• Your preference

• Surgery’s relative risks and benefits

Moreover, Surgery tends to work better for Type 1 TN rather than Type 2 TN.

Well, the available options for surgery are:

Brain Stereotactic Radiosurgery (Gamma Knife)

In this surgical procedure, the surgeon makes use of radiation for diminishing or eliminating the pain and damaging the trigeminal nerve. The highly concentrated amount of radiation is directed towards the root of the trigeminal nerve, where it meets the brain stem. This procedure provides relief gradually and may take up to a month.

This procedure helps to get rid of the pain in most cases. But there is a risk of its recurrence generally after 3 to 5 years. In such cases, the surgery can be repeated or an alternative option can be used. The most common side effect of this procedure is facial numbness, which may occur months or years after the procedure.

Microvascular Decompression

Microvascular decompression is a surgical procedure used for relocating or removing blood vessels that are pressing the trigeminal nerve. In this procedure, the surgeon makes a small hole in your skull and moves away the arteries that are in contact with the trigeminal nerve; and puts a soft cushion between the arteries and the nerve. If a vein is causing pressure on the nerve, then your surgeon may remove it.

If arteries and veins are not responsible for the TN then the surgeon may also cut part of the trigeminal nerve (neurectomy).

This procedure is effective for long-term relief from TN pain. But there is a possibility that in some cases, pain reoccurs after 10 years.

Common risks of Microvascular decompression include:

• Stroke

• Facial numbness

• Facial weakness

• Hearing loss

• Other complications

Rhizotomy

Also, there are other procedures that may be used for treating trigeminal neuralgia, like rhizotomy.

Rhizotomy is a procedure in which your surgeon damages the nerves in order to block pain signals. Types of rhizotomy include:

Radiofrequency Thermal Lesioning

Radiofrequency thermal lesioning is used to selectively destroy the nerve fibers that are causing the pain.

In this procedure, the surgeon keeps you sedated while inserting a hollow needle through your face and guiding it to the specific pain point on the trigeminal nerve. When the needle is positioned, then your surgeon will wake you from sedation for a short time. Through the hollow needle, they insert electrodes and send a mild electric current through its tip. Then the surgeon will ask you for the location where you feel tingling. 

As the surgeon detects the segment of the nerve that is causing the pain, they will make you unconscious again. Then the electrode is heated until it destroys the nerve fibers and creates an area of the lesion.

Temporary facial numbness is a common side effect after this procedure. You may also get the pain again after 3 to 4 years.

Balloon Compression

Balloon compression surgery is used to destroy the nerve fibers that are causing the pain.

In this procedure, the surgeon inserts a hollow needle called a cannula, through your cheek, up to the trigeminal nerve. After that, the surgeon inserts a thin flexible tube (called a catheter) which has a balloon at one end through the hole of the needle. Then they inflate the balloon with the required pressure where the nerve fibers create pain. The balloon compresses the nerve and damages the fibers that cause pain. The surgeon then removes the balloon and catheter at the end of the procedure.

This procedure helps people to get relief from the pain at least for one to two years. Temporary facial numbness is a common side effect of balloon compression surgery.

Glycerol Injection Rhizotomy

In Glycerol injection rhizotomy, the surgeon will insert a hollow needle through your cheek and into an opening in the base of your skull. The surgeon guides the needle by X-ray to a small sac of spinal fluid that surrounds the root of the trigeminal nerve. When the needle is in place, the surgeon injects a small amount of sterile glycerol. The glycerol damages the trigeminal nerve and blocks pain signals.

This procedure typically takes only a few minutes to complete and you can be discharged from the hospital on the same day.

Facial tingling or numbness is a common side effect of this procedure. Also, in some people, pain can reoccur after one to two years of surgery.

Alternative Treatment or Natural Treatment for Trigeminal Neuralgia

Some individuals find an alternative or natural therapies (usually in combination with drug treatment) helpful for managing the pain and the impact it has on their lives (2).

These therapies include:

• Supportive counseling or therapy

• Chiropractic

• Nutritional therapy

• Vitamin therapy

• Biofeedback

• Acupuncture

• Low-impact exercise

• Aromatherapy

• Meditation

• Creative visualization, and

• Yoga

Some Useful Home Remedies

The best use of home remedies in the case of trigeminal neuralgia is to avoid pain triggers. If a person can find out the activities or actions causing the pain or attack, then they can use some home practices to avoid them from occurring in the future. Some of the home remedies are:

• Consuming mashed-up or liquid foods, so that you do not need to chew much.

• Make use of straws for drinking cold drinks

• Avoid consuming cold, hot, or spicy foods

• Not sitting directly close to ACs, fans, etc.

• Preventing drafts of cold air in the house

• Using a scarf to safeguard the face from the wind

What Are The Complications of Trigeminal Neuralgia?

Complications of Trigeminal neuralgia are:

Development of an Infection

The most common complication of trigeminal neuralgia is the development of an infection. This can occur because the nerve becomes inflamed, which makes it more susceptible to bacterial infections.

Another risk factor for developing an infection is taking medications that suppress your immune system, such as steroids or antibiotics.

Facial Paralysis or Paresthesia

Trigeminal neuralgia can also lead to the development of facial paralysis or paresthesia (tingling or numbness). Facial paralysis occurs when the trigeminal nerve has been damaged and cannot send signals to the muscles in the face. If left untreated, facial paralysis could lead to difficulty chewing and swallowing food, as well as difficulty talking clearly because speech requires the use of facial muscles.

Socially Withdrawn

Because of embarrassment and fear of an impending attack patients having severe pain linked with facial twitches can become socially withdrawn.

Dry Eye Syndrome

Another possible complication is dry eye syndrome. Dry eye syndrome causes dryness and irritation in the eyes due to reduced tear production. The reduction of tear production may be the result of inflammation due to trigeminal neuralgia or related conditions such as diabetes mellitus or rheumatoid arthritis (RA).

If you have dry eye syndrome, you may experience symptoms such as stinging/burning sensations in your eyes. Also, the symptoms include blurred vision, sensitivity to light, difficulty with nighttime driving, eye redness, etc.

Depression

The pain in trigeminal neuralgia is very severe and unbearable, and if it is not effectively treated then the patients can develop depression.

What is The Prognosis for Patients With Trigeminal Neuralgia?

Trigeminal neuralgia is not a life-threatening condition but it can be life-altering. It can lead to lifelong pain and can be disabling. Its course is variable. In some patients pain episodes may last for weeks or months, followed by pain-free intervals. In some patients, continuous background facial pain is present simultaneously with Trigeminal neuralgia.

Right diagnosis and appropriate treatment are beneficial for the patients and lead to a good prognosis. The condition is often treated with medication and if necessary, surgery and other therapies are required. Furthermore, the medications may lose effectiveness over time.

There are no proven ways to prevent trigeminal neuralgia, but one can adopt techniques to prevent pain.

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References:

1) Trigeminal Neuralgia

https://www.ncbi.nlm.nih.gov/books/NBK554486/

2) Trigeminal Neuralgia Fact Sheet

https://www.ninds.nih.gov/trigeminal-neuralgia-fact-sheet

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Disclaimer

This article is intended for informational purposes only. Any information associated with this article should not be considered as a substitute for prescriptions suggested by local health care professionals.

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