Diagnosis and treatment of Trigeminal Neuralgia (TN)

Trigeminal neuralgia

Trigeminal neuralgia (TN or TGN) is a chronic pain condition that affects the trigeminal nerve, which controls facial sensation and motor functions like biting and chewing. It’s a neuropathic pain condition. There are two types of trigeminal neuralgia: typical and atypical. The most common form causes severe, sudden, shock-like pain in one side of the face that can last anywhere from seconds to minutes.

These episodes can happen in clusters over the course of a few hours. The atypical form causes a less severe burning pain that is constant. Any touch to the face can set off an episode. Both forms of the disease can occur in the same person. It is considered one of the most painful disorders in medicine, and it frequently leads to depression.

The exact cause is unknown, but it is thought to be related to the loss of myelin in the trigeminal nerve. This can happen as a result of a blood vessel compressing the nerve as it exits the brain stem, multiple sclerosis, stroke, or trauma.

Tumors and arteriovenous malformations are less common causes. It’s a specific type of nerve pain. After ruling out other possible causes such as postherpetic neuralgia, the diagnosis is usually based on the symptoms.

Medication or surgery may be used to treat the condition. The anticonvulsant carbamazepine or oxcarbazepine is usually the first line of defense, and it works in about 90% of cases.

In as many as 23% of patients, side effects occur frequently enough to necessitate drug withdrawal. Lamotrigine, baclofen, gabapentin, amitriptyline, and pimozide are some other options. In their most common form, opioids are ineffective. A variety of types of surgery may be tried in those who do not improve or become resistant to other treatments.

Trigeminal neuralgia affects about one out of every 8,000 people every year. It usually starts in people over the age of 50, but it can happen at any age. Women are more likely than men to be affected.

Signs and symptoms

Trigeminal neuralgiaThis disorder is characterized by episodes of severe facial pain along the trigeminal nerve divisions. The trigeminal nerve is a paired cranial nerve that has three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3) (V3). One, two, or all three branches of the nerve may be affected. Trigeminal neuralgia most commonly involves the middle branch (the maxillary nerve or V2) and lower branch (mandibular nerve or V3) of the trigeminal nerve.

An individual attack usually lasts from a few seconds to several minutes or hours, but these can repeat for hours with very short intervals between attacks. In other instances, only 4–10 attacks are experienced daily. The episodes of intense pain may occur paroxysmally. To describe the pain sensation, people often describe a trigger area on the face so sensitive that touching or even air currents can trigger an episode; however, in many people, the pain is generated spontaneously without any apparent stimulation. It affects lifestyle as it can be triggered by common activities such as eating, talking, shaving and brushing teeth.

The wind, chewing, and talking can aggravate the condition in many patients. The attacks are said, by those affected, to feel like stabbing electric shocks, burning, sharp, pressing, crushing, exploding or shooting pain that becomes intractable.

The pain also tends to occur in cycles with remissions lasting months or even years. Pain attacks are known to worsen in frequency or severity over time, in some people. Pain may migrate to other branches over time but in some people remains very stable.

1–6 percent of cases occur on both sides of the face but extremely rare for both to be affected at the same time. This normally indicates problems with both trigeminal nerves, since one serves strictly the left side of the face and the other serves the right side.

Rapid spreading of the pain, bilateral involvement or simultaneous participation with other major nerve trunks (such as Painful Tic Convulsif of nerves V & VII or occurrence of symptoms in the V and IX nerves) may suggest a systemic cause. Systemic causes could include multiple sclerosis or expanding cranial tumors.

The severity of the pain makes it difficult to wash the face, shave, and perform good oral hygiene. The pain has a significant impact on activities of daily living especially as sufferers live in fear of when they are going to get their next attack of pain and how severe it will be. It can lead to severe depression and anxiety.

However, not all people will have the symptoms described above and there are variants of TN. One of which is atypical trigeminal neuralgia (“trigeminal neuralgia, type 2” or trigeminal neuralgia with concomitant pain), based on a recent classification of facial pain.

In these instances there is also a more prolonged lower severity background pain that can be present for over 50 percent of the time and is described more as a burning or prickling, rather than a shock.

Trigeminal pain can also occur after an attack of herpes zoster, and post-herpetic neuralgia has the same manifestations as in other parts of the body.
Trigeminal deafferentation pain (TDP), also termed anesthesia dolorosa, is from intentional damage to a trigeminal nerve following attempts to surgically fix a nerve problem. This pain is usually constant with a burning sensation and numbness. TDP is very difficult to treat as further surgeries are usually ineffective and possibly detrimental to the person.

Causes (Trigeminal Neuralgia)

The trigeminal nerve is a mixed cranial nerve responsible for sensory data such as tactition (pressure), thermoception (temperature), and nociception (pain) originating from the face above the jawline; it is also responsible for the motor function of the muscles of mastication, the muscles involved in chewing but not facial expression.
Several theories exist to explain the possible causes of this pain syndrome. It was once believed that the nerve was compressed in the opening from the inside to the outside of the skull; but leading research indicates that it is an enlarged or lengthened blood vessel – most commonly the superior cerebellar artery – compressing or throbbing against the microvasculature of the trigeminal nerve near its connection with the pons.

Such a compression can injure the nerve’s protective myelin sheath and cause erratic and hyperactive functioning of the nerve. This can lead to pain attacks at the slightest stimulation of any area served by the nerve as well as hinder the nerve’s ability to shut off the pain signals after the stimulation ends.

This type of injury may rarely be caused by an aneurysm (an outpouching of a blood vessel); by an AVM (arteriovenous malformation);\sby a tumor; such as an arachnoid cyst or meningioma in the cerebellopontine angle or by a traumatic event, such as a car accident.[

Short-term peripheral compression is often painless. Persistent compression results in local demyelination with no loss of axon potential continuity.

Chronic nerve entrapment results in demyelination primarily, with progressive axonal degeneration subsequently. It is, “therefore widely accepted that trigeminal neuralgia is associated with demyelination of axons in the Gasserian ganglion, the dorsal root, or both. ” It has been suggested that this compression may be related to an aberrant branch of the superior cerebellar artery that lies on the trigeminal nerve.

Further causes, besides an aneurysm, multiple sclerosis or cerebellopontine angle tumor, include: a posterior fossa tumor, any other expanding lesion or even brainstem diseases from strokes.
Trigeminal neuralgia is found in 3–4 percent of people with multiple sclerosis, according to data from seven studies. It has been theorized that this is due to damage to the spinal trigeminal complex. Trigeminal pain has a similar presentation in patients with and without MS.

Postherpetic neuralgia, which occurs after shingles, may cause similar symptoms if the trigeminal nerve is damaged.

When there is no apparent structural cause, the syndrome is called idiopathic.

Management (Trigeminal Neuralgia)

TN is sometimes misdiagnosed, as is the case with many other conditions that lack a clear physical or laboratory diagnosis. A TN patient may seek the assistance of a number of different clinicians before a definitive diagnosis can be made.

There is evidence that demonstrates the importance of treating and diagnosing TN as soon as possible. Researchers believe that the longer a patient suffers from TN, the more difficult it may be to reverse the neural pathways that are responsible for the pain. [a citation is required]

Temporomandibular disorder is one of the possibilities for a differential diagnosis. TN must be distinguished from masticatory pain, which has the clinical characteristics of deep somatic rather than neuropathic pain because triggering can be caused by movements of the tongue or facial muscles.

A conventional mandibular local anesthetic block will not provide relief from masticatory pain. If the pain is in the inferior dental branch, a conventional inferior dental local anaesthetic block can be performed quickly by a dentist. This will not stop masticatory pain, but it will stop TMJ pain and other types of pain.

The effect of trigeminal neuralgia

Medical (Trigeminal Neuralgia)

Carbamazepine, an anticonvulsant, is the first line of treatment, with second line medications including baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin, and pregabalin being used as backup. Uncontrolled studies have suggested that clonazepam and lidocaine may be effective in the treatment of migraines.

Treatment of trigeminal neuralgia with antidepressant medications, such as amitriptyline, has been shown to be effective, especially when combined with an anti-convulsant medication, such as pregabalin, in some patients.

Due to the fact that duloxetine is an antidepressant, there is some evidence that it can be used to treat some cases of neuropathic pain, particularly in patients suffering from major depressive disorder. However, it should not be considered a first-line therapy and should only be attempted under the supervision of a medical professional.

In the treatment of TN, there is debate over the use of opiates such as morphine and oxycodone, with varying evidence as to their effectiveness in alleviating chronic neuropathic pain. Opioids are generally regarded as ineffective against TN and should not be prescribed as a treatment option.


In approximately 75% of patients who present with drug-resistant trigeminal neuralgia, microvascular decompression provides relief from pain. In addition to the possibility of pain relief following surgery, there is also the possibility of adverse effects, such as facial numbness. Percutaneous radiofrequency thermorhizotomy, as well as stereotactic radiosurgery, may also be effective; however, the effectiveness diminishes with time after the procedure.

Surgical procedures can be divided into two categories: non-destructive and destructive. Non-destructive procedures include:


Microvascular decompression is a procedure that involves making a small incision behind the ear and removing some bone from the surrounding area. To expose the nerve, an incision is made through the meninges and into the brain. A sponge-like pad is placed between the compression and the nerve to stop unwanted pulsation and allow myelin sheath healing. Any vascular compressions of the nerve are carefully moved out of the way.


All destructive procedures will result in facial numbness, post-operative pain relief, and pain management.

  • Percutaneous techniques, which all involve inserting a needle or catheter into the face up to the origin of the nerve, where it splits into three divisions, and then damaging this area with the intent of causing numbness while also interrupting pain signals, are all available. These techniques have been shown to be effective in a variety of situations, including those in which other interventions have failed and those who are medically unfit for surgery, including the elderly.
  • Balloon compression is the inflation of a balloon at this point, which causes damage and causes pain signals to stop working.
  • Pain signals are hindered by a corrosive liquid called glycerol being deposited on the nerve at this point, resulting in nerve damage and pain signals being hindered.
  • Radiofrequency thermocoagulation rhizotomy is the application of a heated needle to the nerve at this location in order to cause damage.
  • Stereotactic radiosurgery is a type of radiation therapy in which high-powered energy is focused on a small area of the body, such as a tumor.


Researchers have discovered that psychological and social support are essential in the management of chronic illnesses and chronic pain conditions such as trigeminal neuralgia. Chronic pain can be extremely frustrating for both the person who is experiencing it and those who are around them.

History (Trigeminal Neuralgia)

Trigeminal neuralgia has been depicted in Edvard Munch’s The Scream to represent facial pain.First described by physician John Fothergill and surgically treated by John Murray Carnochan, both of whom attended the University of Edinburgh Medical School. Because of 123 cases of TN studied by Harvey Cushing, TN has been known as the “suicide disease” in the past.

Culture and society

TN has been noted in the lives of the following people:

  • According to some accounts, British Prime Minister William Gladstone was infected with the illness.
  • When Melissa Seymour was diagnosed in 2009, she underwent microvascular decompression surgery in a well-documented case that helped to raise public awareness of the illness in Australia. As a result, the Trigeminal Neuralgia Association of Australia named Seymour as a Patron.
  • In 2011, Indian actor Salman Khan was diagnosed with TN. In the United States, he had surgery.
  • Several years ago, Gaelic football star Christy Toye was diagnosed with the disease. His team won the 2014 All-Ireland championship despite him missing the previous year’s campaign due to injury.
  • Former Poplar and Limehouse MP Jim Fitzpatrick revealed that he had trigeminal neuralgia prior to undergoing neurosurgery. At parliamentary meetings, he has spoken openly about his illness, and he is a prominent member of the TNA UK charity.
  • President of the Confederate States of America: Jefferson Davis
  • Pragmatism’s father, Charles Sanders Peirce, was an American philosopher and scientist.
  • Gloria Steinem is an American journalist, activist, and feminist.
  • When Anneli van Rooyen was diagnosed with atypical trigeminal neuralgia in 2004, the Afrikaans singer-songwriter was already well-known in the 1980s and 1990s. When Van Rooyen underwent surgery to alleviate her condition in 2007, she sustained permanent nerve damage and had to nearly retire from performing.
  • HAR, lead singer of the Bad Brains, a hard-core punk band
  • Briton Aneeta Prem, a human rights activist in the UK, is the president and founder of the Freedom Charity. In 2010, Aneeta began experiencing severe pain and sleep deprivation as a result of bilateral TN. Her condition was only discovered in 2017 after a series of tests. UCHL performed MVD Surgery in December 2019 to alleviate right-side pain.

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