Trigeminal Neuralgia

A short circuit in the face's main sensory nerve

Trigeminal neuralgia is sudden, severe, electric-shock or stabbing pain in the face, in the territory of the trigeminal nerve, usually the cheek and jaw, sometimes around the eye, almost always on one side. Attacks are brief but can repeat many times a day, and there are typically pain-free intervals between them.

In most people the cause is a small blood vessel resting against the nerve where it leaves the brainstem; over time the pulsing vessel irritates the nerve's insulation and produces the pain. Less often it relates to multiple sclerosis, and rarely to a tumor pressing on the nerve, which is why imaging is part of the work-up, especially with atypical features.

Brief, triggered, one-sided

The pain is often set off by ordinary, light touch: chewing, talking, brushing teeth, washing the face, or a breeze on the cheek. Between attacks the neurological exam is normal, any persistent numbness or weakness prompts a search for another cause. The pattern (where, what triggers it, how long attacks last, what medications have helped) guides both diagnosis and treatment.

After medication, not before

Medication is the first treatment, and it controls the pain for most people. Carbamazepine (or oxcarbazepine) is the standard first choice; baclofen and gabapentin are often added or used when the first drugs are not tolerated. Surgery becomes an option when the pain no longer responds to well-chosen medication, or when the side effects of the doses needed outweigh the risks of a procedure.

Surgical options

The choice balances how durable the relief is against how invasive the procedure is, and depends on your age, health, and whether a blood vessel is seen on imaging.

• Microvascular decompression (MVD)
  An operation that reaches the nerve where it leaves the brainstem and moves the offending blood vessel away, placing a soft cushion between them. Because it treats the cause rather than the nerve itself, it offers the most durable relief and spares facial sensation, the preferred option for patients well enough for surgery.
• Percutaneous rhizotomy
  A needle passed through the cheek to the trigeminal ganglion interrupts the pain fibers, by radiofrequency heat, a glycerol injection, or brief balloon compression. Less invasive than MVD and often chosen for those who cannot have open surgery; it can cause some facial numbness, and the glycerol technique tends to cause less.
• Stereotactic radiosurgery (Gamma Knife)
  Focused beams of radiation are aimed at the nerve with no incision at all. Relief develops gradually over weeks to months. A good option for selected patients and for pain that returns after another procedure.
• Nerve blocks (for triggers or short-term relief)
  Targeted blocks of an affected branch can calm a trigger or give temporary relief, and can help confirm which division of the nerve is involved before a definitive procedure.

See also