Learn about getting a comprehensive orofacial pain evaluation and become an educated patient.
Trigeminal neuralgia (TN) is also called tic douloureux. In French, tic means “muscle twitch” or “spasm”; douloureux means “painful”. TN is an example of neuropathic pain, arising from the trigeminal nerve (the fifth cranial nerve). New cases of trigeminal neuralgia affect 4 to 5 of every 100,000 people in the United States each year. TN affects women slightly more often than men, and is more common in people over 40.
TN episodes may start as short, mild attacks and progress and cause longer, more-frequent bouts of searing pain. TN pain is described as sudden, intense, “stabbing” or “shock-like”. This pain can occur almost anywhere between the jaw and forehead, including inside the mouth. This pain is usually only on one side of the face, and can include facial twitching (hence, the term ‘tic’).
A constant aching, burning feeling that may also occur before evolving into the spasm-like pain. Many people report that their TN attacks become more intense and frequent over time, sometimes with pain-free periods in between. TN is often confused with dental pain.
The names used to differentiate types of TN may vary from doctor to doctor. In order to provide one internationally accepted naming standard, below is the International Classification of Headache Disorders 3rd Edition. The following classifications are based on a consensus between the International Headache Society (IHS) and the International Association for the Study of Pain (IASP).
Description: Classical trigeminal neuralgia without persistent background facial pain.
An artery or vein compressing the trigeminal nerve causes the intense pain of TN. This type of TN is sometimes referred to as TN1, Type 1, or Classic TN. Classical TN is characterized by sharp, stabbing, paroxysms of severe pain, typically lasting a fraction of a second to two minutes. The paroxysms are very severe in intensity, usually having a trigger zone or an action that will trigger or activate the shock-like jolt. The pain is almost always unilateral (on one side) and located in the second (midface) or third (jaw) trigeminal nerve branches. Pain rarely is seen in the first division (forehead).
The cause of Classical TN is typically nerve compression by a vessel, usually the superior cerebellar artery on the trigeminal nerve root as it leaves the brain stem or pons. Classical trigeminal neuralgia with purely paroxysmal pain is also marked by periods of complete pain-free remissions.
Description: Classical trigeminal neuralgia with persistent background facial pain. People with atypical TN experience a persistent dull ache or burning sensation in one part of the face. However, episodes of sharp pain can complicate atypical TN. There is often not a specific trigger point for the pain;the pain may grow worse over time.
Description: Trigeminal neuralgia caused by an underlying disease.
Description: Trigeminal neuralgia with neither electrophysiological tests nor MRI showing significant abnormalities.
Description: Facial pain in the distribution(s) of one or more branches of the trigeminal nerve caused by another disorder and indicative of neural damage (including herpes zoster, postherpetic neuralgia, and post-traumatic neuropathy).
The medicines doctors typically prescribe to treat trigeminal neuralgia were originally developed to treat epilepsy. However, this class of medications, called anticonvulsants, has been found to be quite effective in treating nerve pain, including trigeminal neuralgia. A positive response to these drugs might signal to your doctor that classical TN is an accurate diagnosis. Carbamazepine and oxcarbazepine are frequency-dependent sodium channel blockers that reduce pain in approximately 90% of people with TN. These drugs are not always well tolerated and need to be titrated (increasing or lowering doses) carefully.
Where there is a continuous or longer lasting dull, burning, aching background pain, the addition of a tricyclic antidepressant such as nortriptyline, in doses around 50-100 mg, at bedtime, may be helpful. Other anticonvulsants such as levetiracetam and zonisamide may be useful but have not been studied in placebo-controlled trials. Baclofen is a muscle relaxant that is very effective in trigeminal neuralgia in doses between 5 and 80 mg daily. Sedation is the most significant side effect. Phenytoin may be used as an alternative in doses of 100 – 300 mg per day.
Stimulus-provoked pain is typical of TN. Triggered pain is one of the signs to your doctor to indicate a diagnosis of TN. In most people, TN pain is triggered by ‘innocuous mechanical stimuli’- that would not hurt someone without TN. Subtle stimuli can be a breeze or light touch of the face. Touch plus facial movements can also trigger pain. Movement alone can also be enough to provoke TN pain. The location of your pain may be different from the location that was stimulated. You may also experience a refractory period of several seconds or minutes after a pain attack when a new attack cannot be provoked.
Attacks of TN may be triggered by:
Your trigger may not be listed here, but that does not mean that you do not have TN.
TN can be very difficult to diagnose, because there are no specific diagnostic tests and symptoms are very similar to other facial pain disorders. Trigeminal neuropathic pain is almost always diagnosed by your description of your symptoms. The Burchiel Questionnaire or the McGill Pain Questionnaire may help your doctors determine how to treat you for your pain.
Your doctor will likely order an MRI scan when TN is suspected in order to rule out multiple sclerosis or a tumor and to look for an offending blood vessel that is causing the pain. High-resolution, thin-slice or three-dimensional MRIs have the ability to show fine trigeminal nerve compression.
Commercial names for high-resolution images are:
It is not likely that your pain will resolve on its own. TN pain usually occurs in cycles, sometimes with periods of remission for weeks, months or even years. Over time, attacks of pain may come more frequently and be increasingly severe.
Cruccu G, Finnerup NB, Jensen TS, Scholz J, Sindou M, Svensson P, Treede RD, Zakrzewska JM, Nurmikko T. Trigeminal neuralgia: New classification and diagnostic grading for practice and research. Neurology. 2016 Jul 12;87(2):220-8. doi: 10.1212/WNL.0000000000002840. Epub 2016 Jun 15. PMID: 27306631; PMCID: PMC4940067.
Dr. Derek Steinbacher, Director of Craniofacial Surgery, Yale Medicine, Chief of Oral Maxillofacial Surgery and Dentistry, FPA Medical Advisory Board member, reviews migraines, TMJ disorders, and dental pain.
Dr. Wolfgang Liedtke will discuss medical treatment of trigeminal neuropathic pain with Dr. Jeffrey Brown.
Wolfgang Liedtke, M.D. Ph.D. is Chair of Neurology, Global Development Scientific Council at Regeneron Pharmaceuticals. Prior to that, he was Professor in the Departments of Neurology, Anesthesiology and Neurobiology; Attending Physician, Duke Neurology Clinics and Clinics for Innovative Pain Therapy, serving patients there for over 17 years.
Dr. Mark Linskey, Dr. Richard Zimmerman, and Megan Hamilton discuss what to look for in the decision making process when you are trying to find a doctor and treatment for facial pain.
Dr. Larry Arbeitman will answer: What is Upper Cervical Chiropractic? How does is differ from traditional Chiropractic methods? Learn about the connection between the Upper Cervical Spine and Facial Pain, research and case studies, what you can expect from UCC and how you can integrate it into your healthcare plan. You will also be able to ask Dr. Arbeitman your questions during this live presentation.
In this webinar, Dr. Jeffrey Brown, Chairman of the FPA Medical Advisory Board, talks about the top questions patients and their loved ones have regarding trigeminal neuralgia.
Dr. Raymond Sekula, Professor of Neurosurgery at the University of Pittsburgh School of Medicine and Director of the Cranial Nerve Disorders Program at UPMC, and FPA Medical Advisory Board member reviews the challenges that can complicate the care of people with neuropathic facial pain.
Dr. Deborah Barrett offers a framework and tools to help people improve their quality of life, just as they are, while also reducing pain and suffering. Her work draws from empirically based cognitive and behavioral interventions, and she practices what she preaches every day.
Dr. Jeffrey Brown, Chairman of the Facial Pain Association’s Medical Advisory Board, interviews Dr. Hossein Ansari on medical causes of neuropathic facial pain.
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Jennifer M. Wagner, Executive Director of the Western Pain Society, explains the brain-body connection with an emphasis on pain response and provides a list of strategies for those affected by chronic pain.
Facial pain can be described in many words…but if you had to choose just one, what would it be? The YPC recently shared how we would describe TN in one word and how we plan to overcome TN.
Dr. Julie Pilitsis, Chair of the Department of Neuroscience & Experimental Therapeutics Professor of Neurosurgery Neuroscience and Experimental Therapeutics, Albany Medical Center and FPA Medical Advisory Board member presents an overview of trigeminal neuralgia and other neuropathic facial pains.
Dr. Konstantin Slavin discusses neuromodulation, a procedure used to treat and enhance quality of life in individuals who suffer severe chronic illness due to persistent pain.
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