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Trigeminal Neuralgia

Trigeminal neuralgia is a painful nerve condition of the face.

What causes trigeminal neuralgia?

Trigeminal neuralgia is a painful condition affecting the trigeminal nerve, the largest nerve providing sensation in the face.  The trigeminal nerve has three divisions. One goes to the area above the eye, one goes near the cheekbone and one goes to the jaw. In trigeminal neuralgia, one or more of these branches is affected, normally just on one side of the head. The first branch is less commonly affected than the other two, so pain over your forehead and around your eye is the least common. 

The nerve may be painful because it or its pathway has been damaged in some way. In many cases the nerve is being squashed by a blood vessel that presses against it as it emerges from the brain stem.   

Trigeminal neuralgia usually occurs in people over the age of 50 and tends to affect women more than men.

What are the symptoms of trigeminal neuralgia?

The most common symptom of trigeminal neuralgia is brief but severe episodes of facial pain that tend to come and go. The pain may start without warning or may be triggered by talking, chewing, or brushing your teeth. Sometimes even touch or cold air on a certain part of the face (a "trigger area") may cause a pain attack. 

A typical attack only lasts for seconds, but may be followed by several more over the space of a few minutes. After this, there may be pain-free periods (remissions) that last for days, weeks or months. 

It is impossible to predict when the next bout of pains will occur, or how often the bouts will recur. The bouts of pains tend to become more frequent as you become older.

Sometimes people may have dull pain between bouts of the more usual severe shooting pain. 

 

What tests may be needed?

After asking about your medical history, your doctor will do a physical examination. People with trigeminal neuralgia usually have a normal physical examination and the diagnosis is based on their symptoms. A CT scan or an MRI may occasionally be needed to see if another medical condition is causing the pain.  Sometimes a specialised technique called an MRI angiogram is used to see if a blood vessel is causing the problem by compressing the nerve.   

What treatment is available?

It is most important to avoid doing those things you know will trigger a pain attack.

Normal painkillers such as paracetamol are not usually effective. Patients and doctors often find that prescription opioids (strong painkillers) can help.  Your doctor may prescribe an antiepileptic drug, as these drugs have been shown to reduce pain (this does not mean you have epilepsy).  The drug that in the past has most commonly been used is carbamazepine, although other drugs such as oxcarbazine, gabapentin or pregabalin can also help.  

Antiepileptics are usually started on a low dose and built up gradually until a dose is reached that stops the pains. You should then take the drug regularly to prevent pains from returning. The dose of antiepileptic needed to control the pains varies from person to person.

It is common to take antiepileptics until about a month after the pains have stopped. The dose may then be reduced gradually, and stopped if possible. There is often a period when pains do not occur for some time afterwards (which is called remission). However, the pains are likely to return. Treatment can then be restarted. Some people find that antiepileptics work better when they first start taking it, than in later years.

Nerve blocks using local anaesthetics can be used to numb the nerve. Alternative treatments such as transcutaneous electronic nerve stimulation or TENS (which uses small amounts of electricity to block pain signals) are sometimes used.

Surgery (in our area done by the neurosurgeons at Frenchay Hospital) is sometimes needed to treat trigeminal neuralgia, but only when other treatment has failed.  One of the procedures that can be used is an operation to decompress the nerve by moving a compressing artery away - a microvascular decompression.  Other techniques such as radiofrequency or glycerol lesioning to the nerve can be used, though these can carry risks of side effects. 

 

 

Links

Pain Felief Foundation information sheet on Trigeminal Neuralgia

Trigeminal Neuralgia Association UK website

We recommend a very detailed site from the University of Manitoba outlining the causes and management of Trigeminal Neuralgia.

 

 

 

 

 

 

 

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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
email: pain.webmaster[at]glos.nhs.uk

Page updated 15/02/2016