Symptoms of Trigeminal Neuralgia

In this article we discuss symptoms of trigeminal neuralgia and available treatments.

Trigeminal neuralgia (also called tic douloureux) is a type of severe facial pain. The pain is like sudden, excruciating, stabbing electric shocks. Typically, it only affects one side of the face. 

There are twelve pairs cranial nerves which originate in the brain, each with a different function for sensation or movement or both. The fifth cranial nerve is called the trigeminal nerve. It is responsible for facial sensation (such as touch, temperature and pain) as well as chewing. 

The trigeminal nerve has three main branches hence its name. Each branch supplies a different area of the face: the ophthalmic branch supplies the upper eyelid and forehead; the maxillary branch supplies the lower eyelid and cheek; the mandibular branch supplies the jaw.

Trigeminal neuralgia is usually caused by a blood vessel (artery or vein) pressing on the trigeminal nerve where it enters the central base of the brain (brainstem). The pressure on the nerve (neurovascular compression) damages the nerve’s insulation (myelin). This causes cross firing of nerves and abnormal electrical activity within the trigeminal nerve so that normal facial sensations such as light touch, wind, brushing teeth or chewing can cause sudden episodes of severe electrical pain.  

Much less commonly, trigeminal neuralgia is caused by multiple sclerosis, a stroke, a tumour, a facial injury or other medical condition.

Trigeminal neuralgia affects women more often than men and is rare in people under the age of 40, although it can occur in younger people. 

If you suffer from trigeminal neuralgia, even mild stimulation of the face can be extremely painful. Trigeminal neuralgia is invariably described by patients to be the worst pain that they have ever experienced. In this article we discuss the symptoms of trigeminal neuralgia to help you identify when to contact a neurosurgeon to discuss treatment options.

Can you have a mild case of trigeminal neuralgia?

Early symptoms of trigeminal neuralgia include mild, short-lived jolts of pain when the face is touched. It often starts near the nose, top lip or corner of the eye. The pain may be bearable at first; however, in most cases the condition will continue to progress and cause increasingly frequent, increasingly severe episodes of extreme pain often also involving the cheek, jaw or sometimes the forehead. Without treatment the condition will likely continue to develop until the pain experienced during attacks becomes unbearable.

What are the symptoms of trigeminal neuralgia?

The symptoms of trigeminal neuralgia can often easily be confused with migraine headaches or dental problems.  As the pain caused by trigeminal neuralgia is often felt in the cheek, jaw, teeth or gums, many people with this condition visit a dentist before going to their GP and some may have teeth extracted to no avail.

Symptoms used to identify the trigeminal neuralgia include:

• sudden, intense, shooting pain that feels like electric shocks on one side of the face or the jaw; or
• a more constant background aching, burning, tingling sensation;
• pain only on one side of the face (not crossing the midline), usually in the cheek or the lower jaw (rarely will it occur on both sides of the face and if it does then not at the same time);
• pain that typically comes and goes, although the condition can be progressive with attacks worsening over time with shorter periods of relief from the pain.
• no changes in the skin or eyes. There are other similar headache conditions that cause symptoms such as numbness of the face, redness of the eyes and tearing. Trigeminal neuralgia does not cause these symptoms.

Everyday activities can trigger the attacks of pain, such as brushing your teeth, shaving, eating, talking, smiling, exposure to cold temperatures such as a light breeze or air conditioning. Attacks can also happen spontaneously with no obvious trigger.

Do I have trigeminal neuralgia?

There is no specific diagnostic test for trigeminal neuralgia. Making the diagnosis often requires an experienced medical specialist.  

As there are other causes of facial pain, it is important to seek medical advice if you experience one or more of the symptoms described above so that other possible causes can be ruled out. Trigeminal neuralgia is mainly diagnosed by precise description of symptoms including details of the pain, where it is felt and how the pain is triggered. 

If you do have trigeminal neuralgia, an MRI (magnetic resonance imaging) brain scan can identify the presence of any vascular compression or can rule out other causes of trigeminal neuralgia such as a tumour or multiple sclerosis. Sometimes the vessels compressing the trigeminal nerve are not reported or the scan is not precise enough to pick up these structures. Therefore, the MRI scan should be reviewed by a specialist prior to ruling out “neurovascular compression” as the cause of trigeminal neuralgia.

Is trigeminal neuralgia treatable?

Simply put, yes. There are a variety of treatment options available for trigeminal neuralgia. 

The attacks of pain of trigeminal neuralgia can sometimes be brought on or made worse by certain triggers so it may help to avoid these triggers if possible.

Trigeminal neuralgia can often be well controlled with medication: Carbamazepine is the gold standard medication and first line treatment. Oxcarbazepine can be used if carbamazepine side effects are not tolerated. Monitoring with blood tests and for skin rash is required when starting these medications because of potential side effects. Other medications, such as pregabalin, lamotrigine, phenytoin baclofen, can be trialled if required. All these medications also have potential side effects; most commonly, sleepiness, difficulty concentrating, forgetfulness or feeling off balance.

A significant group of patients will find that their medication dose needs to be increased as time progresses.  When the medication becomes ineffective, or the side effects are significant they  may wish to consider other treatments. These include percutaneous (through the skin) ablative procedures which work by deliberately damaging the trigeminal nerve to disrupt the pain signals (glycerol injection, radiofrequency rhizotomy or balloon compression), stereotactic radiosurgery or surgery. Of these, surgery has the best long-term cure rate.

The surgical procedure is known as microvascular decompression. This operation deals with the cause of classical trigeminal neuralgia; the blood vessel or vessels pressing on the trigeminal nerve. The vessel is moved away from the nerve and the nerve is protected from the vessel by tiny pieces of Teflon felt. Unlike the other invasive treatment options, surgery relieves pain without intentionally damaging the trigeminal nerve. For most people, surgery cures their trigeminal neuralgia. For these reasons, after trial of medication, surgery (microvascular decompression) is usually the gold standard treatment.

Contact Dr James Laban

If you are concerned about any symptoms you have, do contact us today to book an appointment to see Dr Laban on (02) 8320 0577 and get the diagnosis and help you need.

Dr Laban is a fellow of the Royal Australasian College of Surgeons and of the Royal College of Surgeons of England and has trained, worked, published and presented nationally and internationally. Dr Laban is a specialist cranial surgeon and trigeminal neuralgia specialist.  Dr Laban works out of his North Shore, Northern Beaches and Central Coast consulting rooms. We are open to talk to you between the hours of 8:00am and 5:00pm Monday to Friday.