​Trigeminal Neuralgia

Sudden and severe stabbing or shooting pain in your face for no obvious reason can leave you worried and confused. You have not injured your face, and you are not sick. So, you cannot figure out why your face hurts when you eat, laugh, or even lightly touch it.

There is a term for this terrible facial pain: trigeminal neuralgia (TN). Another name for it is tic douloureux.

The following will help you determine whether your facial pain is trigeminal neuralgia and options for treating it.

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On this page:

• What Is Trigeminal Neuralgia?
• What Are the Symptoms of Trigeminal Neuralgia?
• How Do You Diagnose Trigeminal Neuralgia?
• How Do You Treat Trigeminal Neuralgia?

What Is Trigeminal Neuralgia?

Typical trigeminal neuralgia (TN) is a shock-like pain (also frequently described as a lightning bolt or electrocution) that occurs in the area that is covered by the trigeminal nerve.

The trigeminal nerve is primarily responsible for the sensation of the face. (Movement comes from another nerve, the facial nerve.) The distribution of the facial nerve covers the part of the face in front of the ear from the forehead to the jaw.

TN is one of the most painful neurological diseases.

How common is trigeminal neuralgia?

Thankfully, TN is rare. It affects less than 1% of people, according to StatPerls.

This rarity makes it vital to see an expert for treatment. And UPMC's neurosurgeons have the expertise in diagnosing and treating TN.

What Are the Signs and Symptoms of Trigeminal Neuralgia?

TN symptoms often include:

• Severe, stabbing facial pain. It may feel dull or sharp. It appears suddenly.
• Spontaneous pain due to actions that involve touching or moving the face.
• Facial pain that lasts from several seconds to several minutes.
• Pain in one spot or side of the face at a time. On rare occasions, such as in patients who have multiple sclerosis, TN may affect both sides of the face. This is very rare otherwise.
• Attacks get more intense and frequent over time.

The pain has some typical characteristics:

• It is sharp and shock-like, as opposed to dull, burning, or continuous. This type of pain is perhaps the most important differentiating factor. Although in some forms of trigeminal neuralgia the two kinds of pain exist together.
• Most people remember the first time they had this pain (memorable onset).
• The pain is in the distribution of the trigeminal nerve (from the forehead to the jaw but in front of the ear). The trigeminal nerve has three branches: one affecting the eye, another affecting the cheek, and a third affecting the jaw. Usually TN pain involves one or two of these branches. It can occasionally affect all three.
• It is usually brought on by light touch, cold air, and simple activities such as eating, speaking, brushing your teeth, etc.
• The pain usually has a very dramatic initial response to specific kinds of medication (caramazepime, oxcarbazepime, etc.). This can help your doctor both reinforce the diagnosis but also be a good treatment option for many people for as long as it is effective.

Some other health issues can also cause these symptoms.

Atypical trigeminal neuralgia

Typical TN can cause sharp, shock-like sensations that sometimes accompany a dull, burning pain that is continuous. But when the pain is only dull, burning and continuous, the TN is thought to be atypical. Atypical trigeminal neuralgia has a completely different prognosis and treatment options. The main treatment for atypical TN is pain management.

How Do You Diagnose Trigeminal Neuralgia?

Your doctor diagnoses TN with a physical exam. They will also ask about your history and symptoms and perform other tests.

The first step in evaluating someone's facial pain is to determine whether they have trigeminal neuralgia or some other form of facial pain. This is an extremely important step, as it determines the effectiveness of a variety of treatments.

Your physician will ask a variety of questions to determine if you have typical trigeminal neuralgia. They also will ask questions about prior dental work, difficulty chewing, and current or prior diseases.

They also will perform testing, typically with an MRI scan. This test can help your doctor rule out other health issues, such as:

• A tumor.
• Arteriovenous malformation.
• Dental pain.
• Headaches or migraine.
• Lyme disease.
• Multiple sclerosis.
• Shingles.

Tests to diagnose trigeminal neuralgia

You will need an MRI scan with or without dye to diagnose TN.

Once the type of trigeminal neuralgia is established, an MRI is performed for two reasons:

• To determine if there is a lesion causing the trigeminal neuralgia such as s tumor, a tangle of vessels (arteriovenous malformation), etc.
• To determine if there is a blood vessel, typically an artery, that is pushing on the nerve.

How Do You Treat Trigeminal Neuralgia?

TN responds very well to treatment options and has the best prognosis. For this reason, the first step in a workup is to determine whether a person has typical trigeminal neuralgia or some other form of pain.

Typically, the next step involves trying medications to treat the pain if this has not been done already. Medications can be a long-lasting solution for many patients.

Other interventions can be contemplated either when the medications stop working, if there are significant side effects from the medications, or if it is the patient's preference not to be on any medications.

Medicines to treat TN

Doctors first treat TN with medicine.

Anticonvulsants are the first drugs your doctor will try. These help block the nerve from sending pain signals.

Your doctor may also prescribe other medicines, including antidepressants, to treat the pain.

Medicine doesn't work for everyone. Some people may have side effects from it. Others may have pain that happens even on the drugs.

In such cases, UPMC neurosurgeons often suggest surgery.

Surgery for TN

In the last 25 years, UPMC surgeons have treated more than 20,000 people with TN.

Surgery options include:

• Microvascular decompression.
• Gamma Knife® radiosurgery.
• Percutaneous glycerol rhizotomy.

Microvascular decompression (MVD)

MVD is a less invasive surgery. That means the surgeon uses smaller cuts and special instruments at the end of a flexible tube.

MVD surgery:

• Treats the cause of the problem.
• Offers the most long-lasting relief.
• Has a lower risk of side effects after surgery.

It stops the blood vessel from squeezing the nerve.

To do so, your UPMC surgeon:

• Makes a cut behind the ear and then makes a hole in the skull the size of a silver dollar.
• Uses a thin, lighted camera tube with special tools to find the blood vessel squeezing the nerve. They then
• Pulls the blood vessel away from the nerve and puts a Teflon “pillow" in between to keep them apart.

MVD provides:

• Fast, complete relief in 82% of people.
• Partial relief in 16% of cases. These people may need occasional or low-dose medicine.

One year later:

• 75% of people still have complete pain relief.
• 8% have partial relief.

Fewer than 5% of people have major side effects from the surgery.

MVD works well for trigeminal neuralgia but is not as helpful for atypical trigeminal neuralgia.

Gamma Knife® radiosurgery for TN

Gamma Knife radiosurgery is painless. It uses hundreds of highly focused radiation beams to take action inside the brain.

With this treatment, doctors do not need to cut into the brain.

Before getting Gamma Knife treatment, you must try medicine to treat your TN.

Surgeons typically use Gamma Knife treatment for people:

• With other health issues that make neurosurgery a bad option.
• With pain after neurosurgery.
• At a higher risk for side effects from other treatments.
• Of older age.

UPMC is the nation's leading provider of Gamma Knife procedures.

Over 25 years at UPMC, Gamma Knife has helped nearly 12,000 people with:

• Brain tumors.
• Blood vessel malformations.
• Pain and other problems.

Why Choose UPMC For Trigeminal Neuralgia Care?

UPMC is a pioneer in the treatment of trigeminal neuralgia (TN). Some of the most effective treatments, such as microvascular decompression, were developed and popularized at the University of Pittsburgh.

The UPMC Department of Neurosurgery:

• Is a high-volume center for diagnosing and treating people with TN. Each year, we treat more than 500 people with this health issue. About 100 of them have surgery for TN.
• Takes part in research to improve TN treatments.
• Is a world leader in caring for people with trigeminal and atypical trigeminal neuralgia.