Trigeminal Neuralgia and Atypical Facial Pain
By Lori Montgomery, MD, CCFP
Trigeminal neuralgia (say: try-GEM-uh-nuhl noo-RAHL-juh) is a very specific kind of facial pain that involves the trigeminal nerve (or fifth cranial nerve). It has also been called “tic douloureux,” because of the way that the pain can be very sudden and cause spasms in the facial muscles. It is fairly rare, with only four or five people in 100,000 affected.
Sometimes, facial pain occurs outside the distribution of the trigeminal nerve. It can be the same quality of pain, and seems to involve a dysfunction in a set of nerves, but does not fit the pattern of trigeminal neuralgia. It often is not treated in the same way.
Signs and symptoms
Fibromyalgia affects three to six percent (3 to 6 out of 100) of the population. It varies in severity. Some patients are very mildly affected, while others are very disabled. Some possible symptoms are:
- pain that may be burning, shooting, stabbing, or electric shock-like; triggered by movement, light touch, eating, or even wind
- pain in a very specific pattern, on one side of the face only, most often for a few seconds or minutes at a time with trigeminal neuralgia
- pain sometimes on both sides of the face, often more constant in the case of atypical facial pain
- itching, tingling, or pins and needles sensations
- very sensitive skin, as if you have a bad sunburn
- extreme sensitivity to heat or cold
- certain muscle weakness
- muscle twitching
- sleep disruption (because pain is often worst at night)
In the case of trigeminal neuralgia, the nerve may be compressed by a blood vessel at the point where it leaves the brainstem. There are other things that can compress a nerve, including tumours. Other causes include diseases like multiple sclerosis, which cause damage to a nerve directly.
There are many things that can cause atypical facial pain. It may involve a nerve being compressed (like trigeminal neuralgia). Sometimes it fits a pattern of neuropathic pain without a clear cause. Temporomandibular joint dysfunction is another example of something that can cause pain of this type.
In the case of trigeminal neuralgia, you may need to have a computerized tomography (CT) scan or magnetic resonance imaging (MRI) to find out where the nerve is compressed. Sometimes it is not possible to see the spot where the nerve is irritated. The main reason to order the test is to make sure there is not a treatable cause of nerve compression. This means making sure it is not a problem that surgery might solve.
In the case of atypical facial pain, the tests that are needed will depend on how you describe the pain, and what other medical conditions you have. It may not be possible to find the cause of the pain with tests such as CT or MRI scans.
If there is a clear cause of the trigeminal nerve being compressed, it may be possible to do surgery to remove the problem. There are a number of different procedures that have been used, including burning the nerve, cutting it, injecting it with toxic solution, or relocating the blood vessel that is compressing the nerve. However, there is no clear evidence that any of these treatments is more effective than medicines. Most involve the potential for serious side effects.
For this reason, most patients with trigeminal neuralgia prefer to try medicine first. Carbemazepine is an anti-convulsant medicine that is often useful in managing the pain.
In the case of atypical facial pain, there is usually no surgery or invasive treatment that is useful. This is probably in part because we still do not completely understand what causes it. Carbemazepine may be helpful here as well.
If carbemazepine is not helpful or if you have too many side effects from taking it, other medicines for nerve pain might be tried. Some patients may benefit from:
- tricyclic antidepressants (such as amitriptyline or nortriptyline)
- gabapentin or pregabalin
- tramadol or other opioid-like medicines (such as morphine)
- serotonin-norepinephrine reuptake inhibitors (such as venlafaxine or duloxetine)
- over-the-counter creams containing capsaicin
- gels or creams that include a local anaesthetic such as lidocaine
Acupuncture and TENS
Some patients find things like acupuncture or transcutaneous electrical nerve stimulation (TENS) helpful as well.
Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
- activity pacing
- cognitive behavioural therapy
These self-management strategies can help you to improve your function so you can do more and enjoy life more.
Forssell H, et al. Differences and similarities between atypical facial pain and trigeminal neuropathic pain. Neurology. October 2007;69(14) 1451-9.
Merrison AF, Fuller G. Treatment options for trigeminal neuralgia. British Medical Journal. December 2003;327(7428):1360-61.
National Institute of Neurological Disorders and Stroke, National Institutes of Health. Trigeminal Neuralgia Information Page, www.ninds.nih.gov. Last update November 19, 2008.