Trigeminal neuralgia

Trigeminal neuralgia (TN) is a facial pain disorder in which brief, severe attacks of pain, often described as electric shocks or stabbing, strike one side of the face in the area supplied by the trigeminal nerve. That nerve carries sensation from the forehead, cheek and jaw. Attacks last from a fraction of a second to two minutes and can be set off by light touch, eating, talking, brushing the teeth or a breeze on the face1. Some people also have a continuous, dull pain between attacks1.

Types and causes

The International Classification of Headache Disorders describes three types1:

• Classical TN, in which MRI shows a blood vessel compressing the trigeminal nerve near the brainstem and changing its shape.
• Secondary TN, caused by another disease, most often multiple sclerosis or a tumor pressing on the nerve.
• Idiopathic TN, in which no cause is found.

Contact between a vessel and the nerve is also seen on MRI in people without pain, so it has to be interpreted with the symptoms2. See types and causes.

Diagnosis

TN is diagnosed from the description of the pain and an examination. Dental and jaw problems can cause similar pain and need to be ruled out, sometimes by a dentist3. European guidelines recommend MRI for everyone with TN, to look for a compressing vessel and to rule out multiple sclerosis or a tumor2. See symptoms and diagnosis.

Medicines

The first treatment is an anticonvulsant medicine, carbamazepine or oxcarbazepine, which controls the attacks in most people at first2. Side effects such as drowsiness and dizziness are common, and carbamazepine can rarely cause severe skin and allergic reactions that need urgent medical attention4. Other medicines are added or substituted when these aren't enough or aren't tolerated. See medicines and nonsurgical care.

Surgery and other procedures

Surgery is considered when medicines don't control the pain or their side effects are intolerable2.

• Microvascular decompression (MVD) moves the compressing vessel off the nerve through a small opening behind the ear. European guidelines recommend it as the first-choice operation for classical TN2. In a review of 3,897 patients in 46 studies, about 76% were free of pain without medication at an average follow-up of 1.7 years5. See microvascular decompression.
• Percutaneous procedures (balloon compression, radiofrequency treatment and glycerol injection) damage the nerve slightly through a needle in the cheek, without opening the skull. Stereotactic radiosurgery aims focused radiation at the nerve; its effect takes weeks to months6. These options are less invasive than MVD, but they more often leave some facial numbness, and their effect may not last as long6. See other procedures.

Outlook

TN is not life-threatening, but the pain can make eating, speaking and daily life very difficult. It often comes in episodes separated by pain-free periods. Most people get good control with medicines, surgery or both, and pain that returns after one treatment can usually be treated again. See recovery and recurrence.

About the editor

Dr. Kamran Aghayev

Neurosurgeon, Associate Professor of Neurosurgery · Istanbul

Dr. Kamran Aghayev is a neurosurgeon in Istanbul and an associate professor of neurosurgery, with more than 20 years in practice. He trained in neurosurgery at Hacettepe University in Ankara, completed spinal oncology and neuro-oncology fellowships at the H. Lee Moffitt Cancer Center in Tampa, Florida, and taught there as a clinical instructor before returning to Turkey. He chaired the neurosurgery department at Biruni University in Istanbul from 2017 to 2020. His published work includes a surgical technique for jugular vein decompression in atlanto-styloid compression and the PURED operation for thoracic outlet syndrome, and he is a named inventor on 13 U.S. patents for spinal devices.

How this site is editedkamranaghayev.com

References

1. International Headache Society. ICHD-3, sections 13.1.1–13.1.2 (2018). Source ↩
2. Bendtsen L et al. European Academy of Neurology guideline. Eur J Neurol. 2019;26:831–849. Source ↩
3. NHS. Trigeminal neuralgia: diagnosis. Source ↩
4. NHS. Carbamazepine (Tegretol). Source ↩
5. Holste K, Chan AY, Rolston JD, Englot DJ. Pain outcomes following MVD for drug-resistant TN: systematic review and meta-analysis. Neurosurgery. 2020;86:182–190. Source ↩
6. NHS. Trigeminal neuralgia: treatment. Source ↩

Related pages

• Symptoms and diagnosisHow the pain history, examination, dental assessment and imaging contribute to a clinical diagnosis.
• Types and causes of trigeminal neuralgiaSeparate the cause category from the pain phenotype, and understand why contact and compression are different terms.
• Medicines and nonsurgical careThe roles of prescribed medicines, tolerability, specialist follow-up and support without personal dosing instructions.
• Microvascular decompression for TNTN-specific selection, patient-level procedure terminology, outcome definitions and risks within the wider care pathway.