Trigeminal Neuralgia

Overview
Trigeminal neuralgia is an inflammation of the
trigeminal nerve causing extreme pain and muscle
spasms in the face. Attacks of intense, electric
shock-like facial pain can occur without warning or
be triggered by touching specific areas of the face.
Although the exact cause of trigeminal neuralgia is
not fully understood, a blood vessel is often found
compressing the nerve. Several treatments can
relieve the pain. Each treatment offers benefits, but
each has limitations. You and your doctor should
determine which treatment is best for you.

What is trigeminal neuralgia?

Neuralgia is severe pain caused by injury or
damage to a nerve. The trigeminal nerve is the fifth
(V) cranial nerve, which arises from the brainstem
inside the skull. It divides into three branches and
then exits the skull to supply feeling and movement
to the face (Fig. 1):
Figure 1. The trigeminal nerve supplies feeling and
movement to the face. It has three divisions that branch
• Ophthalmic division (V1) provides sensation to from the trigeminal ganglion: ophthalmic division (V1)
the forehead and eye. provides sensation to the forehead and eye, maxillary
• Maxillary division (V2) provides sensation to the division (V2) provides sensation to the cheek, and
cheek, upper lip, and roof of the mouth. mandibular division (V3) provides sensation to the jaw.
• Mandibular division (V3) provides sensation to
the jaw and lower lip; it also provides
movement of the muscles involved in biting,
chewing, and swallowing.

When the trigeminal nerve becomes irritated, an

attack of intense pain results. Also called tic
douloureux because of the uncontrollable facial
twitching caused by the pain, trigeminal neuralgia is
serious because it interferes with many aspects of a
person's life. Typical trigeminal neuralgia involves
brief instances of intense pain, like an electrical
shock in one side of the face. This pain comes in
repeated waves that last an hour or more. You may
initially experience short, mild attacks, with periods
of remission. But trigeminal neuralgia can progress,
causing longer, frequent attacks of searing pain.

What are the symptoms?

Patients describe an attack as a “pins and needles”
sensation that turns into a burning or jabbing pain,
or as an electrical shock that may last a few
seconds or minutes. In some cases of extreme pain,
patients have even considered suicide. Everyday
activities can trigger an episode. Some patients are Figure 2. Facial areas of trigger zones. Trigger points
sensitive in certain areas of the face, called trigger (circles) have the greatest sensitivity.

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zones, which when touched cause an attack (Fig.
2). These zones are usually near the nose, lips,
eyes, ear, or inside the mouth. Therefore, some
patients avoid talking, eating, kissing, or drinking.
Other activities, such as shaving or brushing teeth,
can also trigger pain.

The pain of typical trigeminal neuralgia usually has

the following features:
1) Affects one side of the face
2) Can last several days or weeks, followed
by a remission for months or years
3) Frequency of painful attacks increases over
time and may become disabling

A less common form of the disorder, called atypical

trigeminal neuralgia, causes a less intense,
Figure 3. FIESTA MRI can detect blood vessels (arrow)
constant, dull burning or aching pain. This pain
that may be compressing the trigeminal nerve.
sometimes occurs with occasional electric shock-like
stabs that may last a day or more. Atypical facial
pain is more difficult to treat. What treatments are available?
A variety of treatments are available, including
What are the causes? medication, surgery, needle procedures, and
Many believe that the protective sheath of the radiation. First line treatment is usually medication.
trigeminal nerve deteriorates, sending abnormal When medications fail to control pain or cause
messages along the nerve. Like static in a intolerable side effects, a neurosurgeon may be
telephone line, these abnormalities disrupt the consulted to discuss other procedures.
normal signal of the nerve and cause pain. Several
factors can cause the deterioration of this protective Medication
sheath: aging, multiple sclerosis, tumors, but most Over-the-counter drugs such as aspirin and
doctors agree that it is caused by an abnormal vein ibuprofen are not effective against trigeminal
or artery that compresses the nerve. neuralgia. Anticonvulsants and muscle relaxants are
prescribed to block the pain signals from the nerve.
Some types of facial pain can result from an Medications are the initial treatment for trigeminal
infected tooth, sinus infections, shingles or neuralgia and are used as long as the pain is
postherpetic neuralgia, or previous nerve injury. controlled and the side effects do not interfere with
a patient's activities. About 80% of patients
experience at least short-term pain relief with
Who is affected?
medications. For effective pain control, medications
Trigeminal neuralgia affects 1 in every 25,000
must be taken on a regular schedule to maintain a
people, and occurs slightly more in women than
constant level in the blood.
men. Patients are usually middle age and older.
Some people with multiple sclerosis also develop
• Anticonvulsants, such as carbamazepine
trigeminal neuralgia.
(Tegretol), oxcarbazepine (Trileptal), phenytoin
(Dilantin), gabapentin (Neurontin), lamotrigine
How is a diagnosis made? (Lamictal), and pregabalin (Lyrica) are used to
When a person first experiences facial pain, a control trigeminal neuralgia pain. If the
primary care doctor or dentist is often consulted. If medication begins to lose effectiveness, the
the pain requires further evaluation, a consultation doctor may increase the dose or switch to
with a neurologist or a neurosurgeon may be another type. Side effects may include
recommended. The doctor examines and touches drowsiness, unsteadiness, nausea, skin rash,
areas of your face to determine exactly where the and blood disorders. Therefore, patients are
pain is occurring and which branches of the monitored routinely and undergo blood tests to
trigeminal nerve may be affected. ensure that the drug levels remain safe and
that blood disorders do not develop. Multiple
Few causes of trigeminal neuralgia are serious. drug therapy may be necessary to control pain
However, the possibility of a tumor or multiple (e.g., Tegretol and Neurontin).
sclerosis must be ruled out. Therefore, a magnetic
resonance imaging (MRI) scan may be performed. • Muscle relaxants, such as baclofen (Lioresal),
An MRI FIESTA scan can detect any blood vessels are sometimes effective in treating trigeminal
compressing the nerve (Fig. 3). The diagnosis of neuralgia. Side effects may include confusion,
trigeminal neuralgia is made after carefully nausea, and drowsiness.
assessing the patient's symptoms.
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Surgery
The goal of surgery is to stop the blood vessel from
compressing the trigeminal nerve, or to cut the
nerve to keep it from sending pain signals to the
brain. Surgical procedures are performed under
general anesthesia, involve opening a hole in the
skull (called a craniotomy), and require a 1 to 2 day
hospital stay.

• Microvascular decompression (MVD) is a

surgery to gently reroute the blood vessel from
compressing the trigeminal nerve by padding
the vessel with a sponge. A 1-inch opening is
made in the skull behind the ear, called a
craniotomy. This opening exposes the
trigeminal nerve at its connection with the
brainstem. A blood vessel (occasionally a
tumor) is often found compressing the nerve.
After the nerve is freed from compression, it is
protected with a small Teflon sponge (Fig. 4).
The sponge remains in the brain permanently.

MVD provides immediate pain relief in 95% of

patients [1]. About 20% of patients have pain
recurrence within 10 years. The major benefit
of MVD is that it causes little or no facial
numbness. The major disadvantages are the
risks of anesthesia and of undergoing an
operation near the brain.
Figure 4. During MVD, a sponge is inserted between the
• Sensory rhizotomy is the irreversible cutting trigeminal nerve and the blood vessel to relieve the
of the trigeminal nerve root at its connection to compression that causes the painful neuralgia attacks.
the brainstem. A small opening is made in the
back of the skull. A stimulation probe is used to
identify the motor root of the nerve. The motor
root, which controls the chewing muscles, must
be preserved. The sensory root fibers, which
transmit the pain signals to the brain, are
severed (Fig. 5). Cutting the nerve causes
permanent facial numbness and should only be
considered for recurrent pain that has not
responded to other treatments.

Outpatient needle procedures

Needle procedures are minimally invasive
techniques of reaching the trigeminal nerve through
the face without a skin incision or skull opening.
They are performed with a hollow needle inserted
through the skin (percutaneous) of the cheek into
the trigeminal nerve at the base of the skull. The
goal of rhizotomy or injection procedures is to
damage an area of the trigeminal nerve to keep it
from sending pain signals to the brain. Damaging
the nerve causes mild to major facial numbness in
that area. A degree of facial numbness is an
expected outcome of the procedure and is
necessary to achieve long-term pain relief. These
outpatient procedures are typically performed under
local anesthesia and light sedation. Patients go
home the same day.
Figure 5. During sensory rhizotomy, the sensory root
fibers are cut, but the motor root is preserved.

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• Radiofrequency rhizotomy, also called
Percutaneous Stereotactic Radiofrequency
Rhizotomy (PSR), uses a heating current to
selectively destroy some of the trigeminal nerve
fibers that produce pain. While asleep, a hollow
needle and electrode are inserted through the
cheek and into the nerve. The patient is
awakened and a low current is passed through
the electrode to stimulate the nerve. Based on
your feedback, the surgeon positions the
electrode so that tingling occurs where your
painful attacks are located. Once the pain-
causing area is located, the patient is put back
to sleep and a heating current is passed
through the electrode to damage only that
portion of the nerve (Fig. 6).

PSR provides immediate pain relief for 98% of

patients [1]. About 20% of patients experience
pain recurrence within 15 years. Medication,
repeat PSR, or another surgical procedure can
be considered. Complications may include
Figure 6. During PSR, a hollow needle is inserted through
double vision, jaw weakness, loss of corneal
the cheek into the nerve. Once the electrode is correctly
reflex, dysesthesia (troublesome numbness) positioned, a heating current is used to destroy the pain-
and very rarely anesthesia dolorosa. Partial causing fibers.
facial numbness in the area where the pain
existed is expected. Other complications, such
as blurred vision or chewing problems, are
usually temporary.

• Glycerol injection is similar to PSR in that a

hollow needle is passed through the cheek to
the nerve. The needle is positioned in the
trigeminal cistern (a fluid-filled area in the
ganglion). Glycerol is injected into the cistern to
damage some of the trigeminal nerve fibers
that produce pain. Because the location of the
glycerol cannot be controlled precisely, the
results are somewhat unpredictable. Figure 7. During radiosurgery, a high dose of radiation is
delivered to the trigeminal nerve root. Over time the
radiation will damage the nerve fibers and interrupt the
Glycerol injection provides immediate pain relief
pain signals.
in 70% of patients [2]. About 50% of patients
experience pain recurrence within 3 to 4 years. • Peripheral neurectomy can be performed to
As with PSR, partial facial numbness is the nerve branches by exposing them on the
expected and complications are similar. face through a small skin incision. Cutting the
supraorbital nerve (branch of V1 division) may
• Balloon compression is similar to PSR in that be advised if pain is isolated to the area above
a hollow needle is passed through the cheek to the forehead. Cutting the infraorbital nerve
the nerve. However, it is performed under (branch of V2 division) may be performed if
general anesthesia. The surgeon places a pain is limited to the area below the eye along
balloon in the trigeminal nerve through a the upper cheekbone. Cutting the nerve causes
catheter. The balloon is inflated where fibers complete facial numbness in the region the
produce pain. The balloon compresses the nerve supplies.
nerve, injuring the pain-causing fibers. After
several minutes the balloon and catheter are Radiation
removed. The goal of radiation treatment is to damage the
trigeminal nerve root to interrupt the pain signals
Balloon compression provides immediate pain from reaching the brain. Stereotactic radiosurgery
relief for 80% of patients [2]. About 20% of is a noninvasive outpatient procedure that uses
patients experience pain recurrence within 3 radiation beams to destroy some of the trigeminal
years. Complications may include minor nerve. A stereotactic mask or frame is attached to
numbness, chewing problems, or double vision. the patient’s head to precisely locate the nerve on
an MRI scan and to hold the head perfectly still

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during treatment. Highly focused beams of radiation Support
are delivered to the trigeminal nerve root (Fig. 7). In Support groups provide an opportunity for patients
the weeks after treatment, a lesion (injury) gradually and their families to share experiences, receive
develops where the radiation occurred. support, and learn about advances in treatments,
pain control, and medications. Please contact the
Pain relief may not occur immediately but rather TNA Facial Pain Association at 800-923-3608.
gradually over time. About 50% of patients have pain
relief in 4 weeks; 75% of patients have pain relief in Sources
8 weeks. Patients remain on medication for a period 1. Taha JM, Tew JM Jr: Comparison of surgical
of time following treatment to control the pain while treatments for trigeminal neuralgia:
the radiation takes effect. Seventy percent of patients Reevaluation of radiofrequency rhizotomy.
are relieved of pain for 2 years. In about 50% of Neurosurgery 38:865-871, 1996.
patients, pain recurs 3 to 5 years after treatment [3]. 2. Tew JM: Therapeutic Decisions in Facial Pain.
Complications include facial numbness and dry eye. Clinical Neurosurgery 46:410-431, 2000
3. Gronseth G, et al.: Practice Parameter: The
Clinical trials diagnostic evaluation and treatment of
Clinical trials are research studies in which new trigeminal neuralgia (an evidence-based
treatments—drugs, diagnostics, procedures, and review). Neurology 71:1183-90, 2008
other therapies—are tested in people to see if they
are safe and effective. Research is always being Links
conducted to improve the standard of medical care. TNA Facial Pain Association www.fpa-support.org
Information about current clinical trials, including American Pain Society www.ampainsoc.org
eligibility, protocol, and locations, are found on the
Web. Studies can be sponsored by the National Facial Neuralgia Resources
Institutes of Health (see clinicaltrials.gov) as well as www.facial-neuralgia.org/
private industry and pharmaceutical companies (see
www.centerwatch.com). Trigeminal Neuralgia Diagnostic Questionnaire,
https://neurosurgery.ohsu.edu/tgn.php
Recovery
No one procedure is best for everyone and each Glossary
procedure varies in its effectiveness versus side anesthesia dolorosa: constant pain felt in an area
effects (see Comparison of Treatment Results for of total numbness; similar to phantom limb pain.
Facial Pain). Microvascular decompression (MVD) and anticonvulsant: a drug that stops or prevents
radiofrequency rhizotomy (PSR) have comparable convulsions or seizures.
rates of pain relief that are highest among the dysesthesia: a numbness, crawling, or unpleasant
available options. In a study of approximately 100 sensation that a person considers disturbing.
patients or more published in the past 10 years, the glycerol: an oily fluid that can be injected into a
rates of pain relief were 77% in 7 years for MVD and nerve to destroy its pain-producing portion.
75% in 6 years for PSR rhizotomy. multiple sclerosis: a chronic degenerative disease
of the central nervous system in which the
Trigeminal neuralgia can recur in divisions of the myelin (sheath) surrounding the nerves is
nerve previously free of pain. This can occur following destroyed.
all treatments and may represent progression of the neuralgia: nerve pain.
underlying disorder rather than recurrence. neurectomy: cutting of a nerve to relieve pain.
percutaneous: through the skin.
Sources & links postherpetic neuralgia: chronic pain that persists
after shingles rash and blisters have healed.
If you have more questions or would like to schedule
radiofrequency: radiant energy of a certain
an appointment with one of our neurosurgeons,
frequency.
please call (515) 241-5760. Our offices are located on
rhizotomy: interruption or destruction of a group
the Iowa Methodist Campus.
of nerve fibers by chemical or radiowaves.
shingles (herpes zoster): a viral infection that
causes a painful skin rash and blisters along the
course of a nerve; a reactivation of chickenpox.
tic douloureux: French for trigeminal neuralgia.

updated > 2.2013

reviewed by > John Tew, MD and Nancy McMahon, RN, Mayfield Clinic / University of Cincinnati Department of Neurosurgery, Ohio
Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic & Spine Institute. We comply
with the HONcode standard for trustworthy health information. This information is not intended to replace the medical
advice of your health care provider. © Mayfield Clinic 1998-2013.

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