As our Pain Doctors regularly explain to patients: “Trigeminal neuralgia (TN), also known as tic douloureux, is a type of neuropathic chronic pain disorder which is sometimes caused by an injury or nerve lesion. It involves sudden attacks of severe facial pain. It affects the trigeminal nerve, or the fifth cranial nerve, which provides feeling & nerve signalling to parts of the head & face. Pain attacks typically last a few seconds (but can last up to 2 minutes) & may occur over and over again several times a day” [1]
The 3 Types of Trigeminal Neuralgia
Here at the London Pain Clinic, our Pain Specialists treat all three categories. These comprise:
Classic Trigeminal Neuralgia: this describes a blood vessel (normally the superior cerebellar artery) pushing on the trigeminal nerve root. It is the most widespread of all the categories
- Secondary Trigeminal Neuralgia: this category of TN is generated by another disorder (e.g., arteriovenous malformation, a tumour, or multiple sclerosis). Of note, patients in this group are more inclined to be younger and experience pain on each side of their face. Moreover, this category affects 15% of TN sufferers.
- Idiopathic Trigeminal Neuralgia: this classification is used when the root cause cannot be determined even after a comprehensive evaluation. This category is the least widespread form of TN [1]
Getting an Accurate Trigeminal Neuralgia Diagnosis
If you are experiencing facial pain, particularly if sensations keep recurring, then the smart move is to make an in-person or online appointment with your Pain Doctor as soon as possible. After they have reviewed your medical history, they will ask you a number of pertinent questions. This will include your symptoms, how your pain first appeared, how frequently you experience it, and what the triggers seem to be.
Your Pain Specialist may also arrange for you to have any necessary tests, scans, and examinations.
The latter can include:
- A neurological examination during which the Pain Doctor examines and touches different areas of the face. This can help ascertain precisely where the pain is occurring. If a patient is thought to have trigeminal neuralgia, then the examination can be beneficial in highlighting which branches of the trigeminal nerve might be impacted.
- A reflex test to determine whether there is any nerve compression, and whether the symptoms are generated by another condition
- An imaging test (e.g., an MRI) which can ascertain whether multiple sclerosis or a tumour is the underlying cause of the trigeminal neuralgia. Note: a dye may be injected into a blood vessel for the purpose of ascertaining the blood flow in the veins and arteries
TN Symptoms to Tell Your Pain Doctor About
These include:
- Episodes that come about for a several seconds to a few minutes
- Brief episodes of shooting or stabbing pain
- Pain triggered by a variety of factors including: a light breeze on your face, applying make-up, shaving, cleansing or washing your face, and tooth brushing
- A aching or burning sensation that can occur prior to feeling intense pain
- Attacks that come on a few times per day or a week, followed by remission
- Pain that as a general rule, only impacts one side of your face
- Pain that could impact just one part of the face or radiate to a broader area
- Episodes that as time passes on, occur at a greater frequency with escalating pain
- Pain primarily in the cheek, gums, teeth, lips and jaw. (The eyes and forehead are not impacted so often)
- Unmanageable facial twitch post-attack [2]
Note: our Pain Consultants are mindful that a number of patients with TN also suffer from anxiety. This is down to not knowing when they may get their next attack.
Holistic Personalised Treatment Plan
As soon as your Pain Specialist has made an accurate diagnosis, they will then devise a Personalised Treatment Plan which you can get started on right away. This can include multiple types of treatment which encompass conventional treatments such as proven pharmaceuticals, and the latest cutting-edge state-of-the-art injectables (such as Botox and pain blockers) as well as other therapies. Your progress will then be periodically reviewed by your Pain Doctor (this can often be done online. These reviews are set up in order to monitor how successful the protocol has been, and whether any additions or adjustments need to be made. It is also an important opportunity for you to ask any questions, discuss how you have been feeling, and telling your Pain Consultant about any trigeminal neuralgia symptoms that you may have been experiencing.
National Institutes of Health Publishes Positive Research on Botox for TN
The “Use of Botulinum Toxin A in the Management of Trigeminal Neuralgia: a Systematic Literature Review” covered: 4 trials with 8 to 12 weeks follow-up to observe changes in VAS [pain rating] & frequency of TN attacks, differences between dosages of BT-A in therapy and side effects. The mean VAS [pain rating] of BT-A group decreased by approximately 68%. Mean frequency of TN attacks in 3 studies of BT-A group decreased by 85%” [3]
Trigeminal Neuralgia Risk Factors & Causes
“It starts with irritation of the trigeminal nerve. You might have a blood vessel pressing on the nerve, damaging the protective coating (myelin sheath) around it. Certain diseases, such as multiple sclerosis, also can injure the myelin sheath. Sometimes, a tumour or a tangle of arteries press on the nerve. Your trigeminal nerve can also be injured — perhaps by surgery, an accident, or a stroke” [2].
Certain people are more inclined to contract trigeminal neuralgia than others.
For example:
- Compared to males, females are more likely to contract trigeminal neuralgia
- TN is more prevalent in people who are aged 50-plus
- Trigeminal neuralgia can run in families. (This could be due to the way in which blood vessels are formed within the brain)
- TN could also be connected to having high blood pressure [2]
Of note, whilst the pain from trigeminal neuralgia can be very strong, this disorder is not life-threatening. However, it has to be said that TN can be a progressive disease, so this means that it can escalate as time goes on. Therefore, it is important to book an appointment with a Pain Doctor as a matter of priority.
Consulting a Pain Doctor to Avoid Facial Pain Misdiagnosis by GPs & Dentists
As the London Pain Clinic is all too aware: “symptoms related to facial pain can be complex. They may not fall into any one specific category. Some people with neuropathic facial pain are misdiagnosed as having dental or other issues. Commonly, people are misdiagnosed as having a dental or other issue, only to find that they have a neuropathy. Until you have an accurate diagnosis that involves a systemic approach to examination [from a Pain Doctor who unlike a GP or dentist, has undergone years of additional training & clinical experience], you may be getting unnecessary & even harmful treatment, & the case of pain, is not being addressed” [4]
References
[1]. National Institutes of Health (2024). “Trigeminal Neuralgia.”
[2]. Durning, M. V. (2024). “Trigeminal Neuralgia.” WebMD
https://www.webmd.com/pain-management/trigeminal-neuralgia
[3]. NIH (2020). “The Use of Botulinum Toxin A in the Management of Trigeminal Neuralgia: a Systematic Literature Review – PMC,” as cited in J Oral Maxillofac Res. 2020 Jun 30;11(2):e2.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7393930/
[4]. The Face Pain Association (2024). “Understanding Facial Pain.”
https://www.facepain.org/understanding-facial-pain/face-pain-diagnosis/
