Trigeminal Neuralgia

You might have stumbled upon this blog because you, or perhaps a loved one, has been suffering from this and you don’t know how to deal with it.  My friend, the first step to dealing with the pain is knowing what it is.  

In this blog, I would like to dissect what is Trigeminal Neuralgia – its symptoms, causes, diagnosis and treatment. Hopefully, this will help you face this condition head on.  

As the old Buddhist saying goes, “Pain is inevitable, but suffering is optional”. You have the power to do something about it.

Do you recognize these symptoms?

• “Electric shock or stabbing pain to one side of the face”
• “Shooting pain radiating to the cheek, haw, teeth, gums”
• “Attacks of one-sided facial pain lasting from seconds to minutes or even longer”
• “Severe facial irritation triggered by touching the face or wind blowing”
• “Facial pain triggered by chewing, or speaking”
• “There is a burning or aching sensation on my face”
• “The pain is sometimes followed by twitching of my facial muscles!”

These are the symptoms reported by patients with Trigeminal Neuralgia, or Tic Douloureux, or sometimes known as the most excruciating pain known to mankind. If you have these symptoms, the first best step will be is to consult with your physician to confirm the diagnosis and to make sure that it is not something else.  

There is no single descriptor of pain but it is usually felt like a burning or electric-like excruciating pain involving one side of the face, resulting from irritation to the trigeminal nerve, as seen in the distribution in the image below:

Initially, the pain usually lasts for a few seconds to a few minutes, that run in cycles.  The frequency of attacks ranges from once a day up to a dozen or more every hour.  

The pain may either be an excruciating sharp, electrical shock pain or a burning and stabbing pain, or both.  

The patient is often left with an uncontrollable facial twitch or tics, hence the other name, tic douloureux.  Just like in any condition, there is no one pain pattern or description for all patients. So it is important to know these symptoms.

The pain is so bad that it may lead the patient to have depression, anxiety, difficulty sleeping and even social isolation.

They can be suffering from all of these and yet, no one would know because the condition does not have any specific physical findings that others see. Indeed, this condition is both physically and mentally debilitating.

About Trigeminal Neuralgia

Neuralgia is the term used to describe pain that is associated with a nerve injury or neuropathic pain. In this case, it is an injury to the Trigeminal Nerve or the cranial nerve that transmits sensation from the face to the brain.  Every year, around 150,000 people are diagnosed with the condition.  

It may occur in any age group, but it is most often seen among patients older than 50years old, and more commonly seen among females. Genetics also comes into play for patients with relatives with blood vessel formation disorders.

If you or your loved one have Trigeminal Neuralgia, it does not mean that it is the end of the world already. You can do something about it. Several treatment options for have been researched and developed.  

As an overview, the goal of treatment is to block the pain signals brought about by the damaged Trigeminal Nerve either through medications, surgery or even complementary approaches.  

Although there are still a lot of things to know about the disease in terms of its cause, more so in terms of the pain management, research is continuously being done to provide the patients with viable pain management solutions.

Confusion in Diagnosing

The close proximity of the facial structures, especially on the jaw area, raises some issues of confusion among patients and health professionals alike.

The jaw pain experienced by some patients may lead them to think of a dental-related condition such as a dental abscess or dental carries. But when they go to their dentists for root canal extraction, they would realize that the pain will not be relieved.  

Some literature would point that dental surgery is in itself is a risk factor for Trigeminal Neuralgia.  However, some doctors and dentists believe that the procedure might have just been coincidental event when the patient is already presenting with initial symptoms of Trigeminal Neuralgia.  

A clear story of the patient’s pain progression and triggers can go a long way especially since imaging is not a routine procedure to diagnose Trigeminal Neuralgia.  

Here are the other conditions that might also be confused as Trigeminal Neuralgia:

• Cluster Headache but this hurts longer and would sometimes have autonomic symptoms
• Migraine Headache is also longer lasting like Cluster Headache but this is often triggered by loud sounds or bright lights
• Otitis Media is an infection of the middle ear and the pain will be localized to the ear
• Giant cell arteritis or inflammation of the blood vessel that presents with persistent pain at both temples of the head

Tumor in the brain that also presents with other neurologic signs or symptoms

This highlights the need for a thorough physical examination by the doctor.  Trigeminal Neuralgia would usually have a normal examination, except for those associated with Multiple Sclerosis and Tumor near the trigeminal nerve root.  

That is why an abnormal physical examination will most likely suggest a different diagnosis.

Medical Explanation - Definition, Symptoms, Causes

We learned from Biology that there are 12 Cranial Nerves in the Human Nervous System.  

These allow us to see, hear, feel, taste and smell things, move our eyes, mouth and face, and a lot more wonderful regulatory functions that we need to survive and enjoy life.  

Trigeminal Nerve is the 5th of these Cranial Nerves. It transmits the sensations of touch, temperature and pain our face feels, to the brain to be processed.  

On normal circumstances, this is the nerve that makes you feel when you are being kissed on your lips, or slapped on the cheek.  

In simple terms, this nerve makes us feels things. Pain alerts us that there is something wrong in our body – such as an aching tooth that might have to be extracted or a pimple you accidentally popped.  

Usually the pain is proportional to the injury. However, in Trigeminal Neuralgia, it makes you feel more than what you should feel to the point of causing some pain.  

This is called hyperesthesia. This happens when the nerve gets disturbed such as in the following conditions:

• Blood vessel or arteriovenous malformation compressing the trigeminal nerve
• Multiple sclerosis or a neurologic condition that destroys the myelin covering of nerves
• Tumor pressing on the trigeminal nerve
• Injury to the trigeminal nerve from surgery or trauma

Any of these causes damage to the trigeminal nerve that leads to the altered transmission of sensations causing neuropathic pain.  

In this scenario, a gentle breeze of air to your cheek might be interpreted by your brain as an excruciating, shock-like sensation. It is so debilitating that it can affect a person’s activities of daily living such as brushing teeth, shaving, putting on make up, eating, drinking, talking, or even going outdoors! because, yes, you guessed it right... they all trigger the pain!

Diagnostic Criteria and Tests

The diagnosis for Trigeminal Neuralgia is primarily clinical which means that the patient will most likely be diagnosed through patient interview of symptom trigger and progression, and physical examination.  As mentioned previously, physical examination for Trigeminal Neuralgia will most likely be normal but it will help rule out other conditions.  

Imaging modalities maybe requested if there is suspicion of Multiple Sclerosis, or an autoimmune disease that damages the myelin sheath or a mass that presses on the trigeminal nerve.  

These cases will also have other neurologic symptoms or affectation of both sides of the face.  In these cases, a Magnetic Resonance Imaging or MRI where the patient enters a huge doughnut shaped machine will most likely be requested.  Imaging may also be helpful in pre-surgical assessment.  

Electrophysiological Studies can also help differentiate between a Classical Trigeminal Neuralgia where there is no other neurovascular compromise is suspected and  Secondary Trigeminal Neuralgia where there is an underlying cause.

Electrophysiological Studies is an examination where metal probes are used to test the integrity of the Trigeminal Nerve by checking the flow of electrical signal through the nerve.

In case of Classical Trigeminal Neuralgia, the International Headache Society has set a Diagnostic Criteria, under the International Classification of Headache Disorders(ICHD-3).

A. Recurrent paroxysms of unilateral facial pain in the distribution(s) of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C

B. Pain has all of the following characteristics:

1. lasting from a fraction of a second to 2 minutes
2. severe intensity
3. electric shock-like, shooting, stabbing or sharp in quality

C. Precipitated by innocuous stimuli within the affected trigeminal distribution

Not better accounted for by another ICHD-3 diagnosis.

Conventional Treatment Methods

The goal of treatment is to block the pain signals brought about by the damaged Trigeminal Nerve.  The conventional treatments for Trigeminal Neuralgia primarily involve medications and surgical procedures.  Doctors usually start patients with medication and if patients do not respond, they are offered surgical procedure.  

Although there is not enough evidence that directly compares the two, not a lot of patients is a fan of medical management.  In fact, in terms of quality of life, a hypothetical survey done by Spatz, Zakrzewska, J., &Kay, E. (2007). revealed that medical management was the least favorite of the interventions.  This is most likely because of the side effects that come with the medications.  

You see, most of these medications act directly on the brain to inhibit the pain signals.  These include mostly anticonvulsants and sometimes, muscle relaxants.  Because of this, they can cause dizziness, tiredness, sleepiness and difficulty concentrating, among others, that may affect a person’s daily activities.  

On the other hand, surgical management like microvascular decompression, while achieving the most sustained pain relief, are invasive procedures that also have some risks such as infection, stroke, bleeding, and sensory or hearing loss.  In this situation, the risks should be weighed against the benefits.  This highlights the need for a good relationship between the patient and the doctor so that the patient receives the best care possible.

Overlap of symptoms with Other Conditions

Trigeminal neuralgia, in few instances, can also have symptoms that can be found in other conditions.  

In a study of Simms, H. and Honey, C. (2011), two-thirds of patients with Trigeminal Neuralgia had at least 1 autonomic symptom.

The symptom is closely associated to the innervated organs of the affected branch of the Trigeminal Nerve. Say, in the first division of Trigeminal Nerve, a patient may have drooping of eyelids, discoloration of the conjunctiva or excessive tearing.  In patients with second division affectation, they may present with facial edema.  Lastly, if the third division is affected, patient may have drooling.

Headache is not a common symptom of Trigeminal Neuralgia but in a case report by Kataria, S. (2020), a patient presenting with severe headache was actually considered to have Trigeminal Neuralgia.

The patient was initially managed as a case of Migraine Headache but when the patient did not respond to conventional migraine treatment, Trigeminal Neuralgia was considered.  

Medicine is indeed both a science and an art. Even though we have already talked about the diagnostic criteria, in some interesting cases, it will still cause confusion among patients and doctors alike.  

This is where the importance of following up, connecting with the patient and thinking outside the box will matter.

In these scenarios, the more logical explanation is most likely an atypical presentation of Trigeminal Neuralgia. Nonetheless, an actual overlap can still happen and should still be worked up.

Self-Help: remedies, practices to find some relief

While medication and surgery are the mainstay of treatment for Trigeminal Neuralgia, their associated side effects and risks have the potential to discourage some patients.

Good thing that Khanal, D., Kathri, S., and Anap, D.(2014) have explored into the non-pharmacological and non-invasive pain treatment for Trigeminal Neuralgia. Their approach that revolves in the realm of physical therapy has shown significant improvement in pain.  

Some of these techniques may be applied as self-help remedies but specific exercises and specialized techniques, and use of electrotherapeutic modality are best done under the supervision of a physical therapist.  

The management they did are highlighted in the following section:

Pain Education – Again, the first step to dealing with the pain is knowing what is it. Learning about the anatomy of the trigeminal nerve and how it causes pain will increase your understanding, decrease your anxiety, and potentially increase compliance with the treatment program.  

Avoidance of trigger – Simple things can trigger an attack and simply avoiding them can already go a long way.  Of course, you cannot stop your daily self-care activities but here are some things that might help to avoid an attack:

• Avoid cold water for drinking or washing face
• Use a scarf to avoid exposure of the face to the cold or windy environment
• Avoid eating hard foods
• Chew foods on the unaffected side

Transcutaneous Electrical Nerve Stimulation (TENS) – The use of an electrotherapeutic modality ha also shown to decrease pain by masking the pain stimulus with the electric current felt over the affected facial area.  This is an intervention that needs to be supervised by a healthcare professional to avoid misuse of the equipment.

Exercises – They have observed that a lot of patients with Trigeminal Neuralgia also has muscle spasm on the neck area because of stiff posture brought about by pain.  This can contribute to the pain of the patients.

Decreasing muscle spasm by warm compress on the neck area along with free neck movement exercises and isometric neck exercises can potentially decrease the pain felt by patients with Trigeminal Neuralgia.  

Relaxation techniques – Patients may also benefit from practicing deep breathing exercises for 10 minutes to decrease anxiety and promote relaxation. Distraction techniques to avoid idle sitting and thinking of pain may also be helpful.

Desensitization Technique – Dabbing the affected side of the face with soft cloth or cotton pad for 15 minutes may help condition the brain to “get used to” the stimulation on the Trigeminal Nerve. This can then decrease the pain sensation during an attack.  

We may not have a choice in some of the diseases that we acquire or inherit but we definitely can do something about our conditions.  

The perfect example of this is Trigeminal Neuralgia. You may have been dealt with this card but there are ways you can deal with it.  

Again, as the old Buddhist saying goes, “Pain is inevitable, but suffering is optional”. You have the power to do something about it.

Why nothing seems to work?

Because probably you, like myself, experience symptoms on the intersection of several conditions such as ON, CGH, Migraine, Tension headaches, and more.

Since we are dealing with the mix symptoms (research is not yet clear on how it all manifests), targeting one symptom in isolation is a painful (and costly) waste of time.

We need to address underlying processes on a more global scale that sometimes means getting results which are not immediate but sustainable (assuming you are not fainting right at this moment because of unbearable pain; call emergency now if that's the case).

The idea is:  Let's deal with the pain and distress so we can have energy, motivation, and mental clarity for a more radical treatment.

‘The time to fix the roof is when the sun is shining.’

We're going to prepare ourselves (help the sun to come out) in order for the true healing process to even begin (fixing the roof).

Physical pain and emotional frustration (resulting from not understanding what's happening and how to deal with it) is what turns our lives into a miserable existence. Generally, we experience a lack of will to do anything until this continuous confusion goes away.

You can learn here why your emotional and mental states can literally generate physical pain.

We need to clear the fog, so to speak, in order to breath freely for a moment so we can gather energy and realize that there's a way out of all this.

Let's do it.

I've created a simple, easy-to-follow model for self-healing. It's simple. It's universal. It's free.

Here are some of the references used for this article:

1. American Association of Neurological Surgeons (n.d.) Trigeminal Neuralgia. AANS. Retrieved fromhttps://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Trigeminal-Neuralgia
2. International Headache Society(2019) Neuropathies & Facial Pains and other headaches. IHS. Retrieved fromhttps://ichd-3.org/
3. Kataria, S. (2020). Trigeminal Neuralgia Induced Headache: A Case Report and Literature Review. Cureus. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430534/
4. Khanal, D., Kathri, S., and Anap, D.(2014) Is there Any Role of Physiotherapy in Fothergill’s Disease. Journal of Yoga & Physical Therapy. Retrieved fromhttps://www.longdom.org/open-access/is-there-any-role-of-physiotherapy-in-fothergills-disease-2157-7595.1000162.pdf
5. Macianskyte, D., et al. (2011)Associations between chronic pain and depressive symptoms in patients with trigeminal neuralgia. Medicina. Retrieved fromhttps://pubmed.ncbi.nlm.nih.gov/22112988/
6. Mayo Clinic. (n.d.) Trigemina lNeuralgia. Mayo Clinic. Retrieved fromhttps://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/syc-20353344
7. National Institute of Neurological Disorders and Stroke (2020) Trigeminal Neuralgia Fact Sheet.  Retrieved fromhttps://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/trigeminal-neuralgia-fact-sheet
8. Obermann, M. (2010) Treatment options in trigeminal neuralgia. Therapeutic Advances in Neurologic Disorders. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002644/#bibr48-1756285609359317
9. Simms, H & Honey, C (2011).The importance of autonomic symptoms in trigeminal neuralgia. Journal of Neurosurgery. Retrieved fromhttps://thejns.org/view/journals/j-neurosurg/115/2/article-p210.xml
10. Spatz, Zakrzewska, J., &Kay, E. (2007) Decision analysis of medical and surgical treatments for trigeminal neuralgia: how patient evaluations of benefits and risks affect theutility of treatment decisions. Pain Journal of the International Association for the Study of Pain. Retrieved from https://journals.lww.com/pain/Abstract/2007/10000/Decision_analysis_of_medical_and_surgical.12.aspx