Trigeminal neuralgia is a debilitating nerve pain disorder involving sudden, severe facial pain. When the trigeminal nerve is damaged or compressed, the pain can be so intense that it is often described as one of the most excruciating pains ever known to humankind. 

Pain attacks can occur unexpectedly and can be physically and emotionally incapacitating. However, various treatments now offer hope of relief.  

Approximately 15,000 people in the United States are diagnosed with trigeminal neuralgia each year. Sometimes referred to as tic douloureux, it occurs slightly more commonly in women and people over 50.

Trigeminal neuralgia symptoms

The trigeminal nerve, or the fifth cranial nerve, sends signals to parts of the head and face. The nerve can be irritated by different conditions, such as tumors, infection, or neurological disorders such as multiple sclerosis. This can manifest as trigeminal neuralgia. However, the most common cause is thought to be due to a blood vessel, often an artery, compressing the trigeminal nerve near the brainstem at the base of the skull. 

“The main symptom is intense facial pain, with sudden episodes that come and go and vary in duration,” says neurosurgeon Mithun Sattur, MBBS. “The pain is described as excruciating, stabbing or electrical in nature. It’s like a sudden electric voltage shock that seizes them, rendering them functionless for seconds to minutes, and then it’s gone. A patient can potentially have 40 attacks in a given day, so about every 30 minutes, this pain seizes them, but between those episodes, they are typically pain-free.”

Trigeminal neuralgia occurs most commonly on one side of the face in distinct areas. While there can be extended periods without pain, the condition rarely goes away without treatment.

Pain areas occur in three facial regions, either alone or in combination:  

• Upper face.
• mid-range face, including upper jaw.
• Lower face along the jawline (most common).

Trigeminal neuralgia pain can be triggered by simple, everyday things, including:

• Talking or smiling.
• Chewing, brushing teeth, applying makeup or shaving.
• Touching the face. Some people can identify a specific spot called a trigger zone.
• An outside breeze.

Trigeminal neuralgia is not classically associated with:

• Ear pain, typical headaches or dizziness.
• Pain in the neck, shoulders or arms.
• Pain that continues for a whole day or days at a time.

People who have had trigeminal neuralgia for many years can experience lingering symptoms between intense episodes.

How trigeminal neuralgia is diagnosed

A trigeminal neuralgia diagnosis is primarily based on a medical exam and how you describe your symptoms to your primary care doctor. If your doctor suspects trigeminal neuralgia, you will be referred to a neurologist or neurosurgeon for further evaluation. 

“A diagnosis is always clinical based on the words a patient uses to describe their pain,” says Dr. Sattur. “After a diagnosis, we order an MRI to rule out any other causes, such as a tumor or multiple sclerosis and to determine the severity of blood vessel compression on the nerve.”  

If an MRI taken for another reason shows a blood vessel problem near the trigeminal nerve but you do not have facial pain, it does not indicate future development of trigeminal neuralgia. Treatment is not recommended without symptoms.

Trigeminal neuralgia treatments

Several treatment options can provide significant and durable pain relief. Because it may recur, working closely with a neurologist to manage the condition long-term is essential. 

The best treatment depends on individual factors such as the severity and frequency of the pain, age and overall health. Treatment typically begins with the least invasive therapies. 

Medications

Anticonvulsant medications work to block pain signals with the hope of reducing attack frequency. Carbamazepine and oxcarbazepine are often tried first, followed by other options such as gabapentin or baclofen. Different drugs or combinations may be tried if symptoms persist or become less effective over time. A neurologist will monitor and make adjustments as needed. 

Surgical options

Surgery may be an appropriate next step if medications do not provide adequate pain relief, side effects become bothersome, or an MRI reveals a tumor. A neurosurgeon will discuss your options with you, along with the risks and benefits of each.

Stereotactic radiosurgery

Stereotactic radiosurgery is a noninvasive procedure that delivers a precise, high radiation dose to the affected area of the trigeminal nerve to reduce pain signals. This approach is a one-time treatment that has a lower risk of facial numbness compared to percutaneous techniques. However, pain relief typically requires few weeks to take effect. 

Percutaneous procedures

Minimally invasive outpatient percutaneous procedures target the trigeminal nerve at the skull base using a balloon or a radiofrequency probe. Performed with anesthesia, balloon compression, for instance, disrupts the abnormally firing signals in the nerve and can reduce or eliminate pain. Treatment causes some facial numbness.

Microvascular decompression surgery

This microsurgical brain surgery procedure (called MVD) physically separates the compressing blood vessel from the nerve. The procedure has the benefit of relieving pain immediately without causing facial numbness and has the best long-term success, but it is conceptually more invasive. The risks are low in expert hands. 

“If you’ve been experiencing facial pain, talk with your doctor,” advises Dr. Sattur. “There’s no reason to continue to suffer. If you have trigeminal neuralgia, we offer effective treatments that can help alleviate or eliminate your pain.”