Trigeminal Neuralgia

Trigeminal neuralgia is a chronic pain condition affecting the trigeminal nerve, which carries facial sensations to the brain. It causes sudden, severe episodes of pain, often described as electric shock-like sensations, affecting areas such as the cheek, jaw, teeth, gums, lips, or, less commonly, the eye and forehead. Pain episodes can occur in rapid succession, lasting from a few seconds to several minutes, and may be triggered by everyday activities: eating, talking, shaving, brushing teeth, or even a light breeze on the face. The intensity and unpredictability of these episodes can interfere with daily activities.

Dr. Teo Kejia

Senior Consultant Neurosurgeon

MBBS (Singapore) | MRCS (Edinburgh) | FAMS (Neuro.Surg) | FRCS Ed (Neuro.Surg) | IFAANS

Symptoms causes diagnosis treatments prevention FAQ

Symptoms of Trigeminal Neuralgia

Patients with trigeminal neuralgia experience several characteristic symptoms that distinguish this condition from other facial pain disorders.

Sudden, severe pain: Episodes of intense, electric shock-like pain that affect one side of the face, following the path of the trigeminal nerve through the cheek, jaw, teeth, gums, or lips. The pain typically lasts from a few seconds to several minutes.
Trigger zones: Specific areas of the face that, when touched or stimulated, trigger pain attacks. These sensitive areas are commonly found around the nose, lips, or cheeks.
Pain-free periods: Intervals between painful episodes where patients experience no pain, which can last for months or even years before pain recurs. Over time, these pain-free periods tend to shorten.
Unilateral pain: Pain that typically affects only one side of the face, most commonly the right side. In rare cases, both sides may be affected, though not simultaneously.
Clustering of attacks: Multiple episodes that occur in succession, with individual attacks lasting seconds to minutes. Some patients report experiencing dozens of attacks daily during severe periods.

Causes and Risk Factors

Trigeminal neuralgia develops through various mechanisms that create pressure on or damage to the trigeminal nerve.

Blood vessel compression

A common cause is a blood vessel pressing against the trigeminal nerve root near where it enters the brainstem, wearing away the protective myelin sheath. This compression creates abnormal transmission of sensory signals to the brain.
Tumours

Growths that press against the trigeminal nerve or its branches can trigger neuralgia symptoms. These may include acoustic neuromas, meningiomas, or epidermoid cysts.
Multiple Sclerosis

The demyelination in multiple sclerosis can involve the trigeminal nerve, resulting in neuralgia.
Ageing

Incidence increases with age, with most cases diagnosed in people over 50 years. The natural ageing process may contribute to nerve vulnerability and vascular changes.
Structural abnormalities

Skull base deformities or arteriovenous malformations can create pressure on the trigeminal nerve roots, causing pain symptoms.

Diagnostic Methods

Clinical Examination and History

A detailed assessment of pain characteristics, triggers, and distribution along the trigeminal nerve branches. Diagnosis is primarily clinical, based on the distinctive nature of pain, its triggers, and its pattern.

Magnetic Resonance Imaging (MRI)

High-resolution brain MRI with specialised sequences, such as CISS (Constructive Interference in Steady State) or FIESTA (Fast Imaging Employing Steady-state Acquisition), provides detailed imaging of the trigeminal nerve. This helps detect vascular compression, tumours, or demyelinating plaques.

Magnetic Resonance Angiography (MRA)

Focuses on blood vessels that may be compressing the trigeminal nerve. MRA helps in surgical planning by identifying the specific vessels involved and their anatomical relationship to the nerve.

Trigeminal Reflex Testing

Neurophysiological tests that measure nerve function by recording electrical responses to stimulation. These tests can detect abnormal conduction that may not be apparent on imaging.

Differential Diagnostic Blocks

Temporary nerve blocks with local anaesthetics help determine if pain originates from the trigeminal nerve. This technique distinguishes trigeminal neuralgia from other causes of facial pain, such as dental conditions or temporomandibular joint disorders.

Treatment Options

The management of trigeminal neuralgia typically follows a stepwise approach, beginning with medication and progressing to more invasive procedures when necessary.

Non-Surgical Treatment

Anticonvulsant Medications: Carbamazepine is the first-line treatment, helping to reduce the nerve’s ability to transmit pain signals. However, its effectiveness may decrease over time.
Alternative Medications: Oxcarbazepine, gabapentin, pregabalin, or baclofen may be used if carbamazepine is ineffective or not well tolerated. These can be prescribed alone or in combination for better pain control.
Tricyclic Antidepressants: Amitriptyline and nortriptyline help modify pain perception pathways in the brain. These are particularly useful for Type 2 trigeminal neuralgia, which involves constant background pain.
Botulinum Toxin Injections: Botox injections into trigger zones can provide temporary relief for several months. This works by blocking pain signals and reducing muscle contractions that may contribute to nerve irritation.

Surgical Treatment

Microvascular Decompression: A surgical procedure that identifies and repositions blood vessels pressing on the trigeminal nerve root near the brainstem. This approach offers the highest likelihood of long-term pain relief but carries the risks associated with major neurosurgery.
Stereotactic Radiosurgery: A non-invasive procedure (Gamma Knife) that delivers focused radiation to the trigeminal nerve root, disrupting pain signal transmission. Pain relief develops gradually over weeks to months, making it suitable for patients who cannot undergo open surgery.
Percutaneous Procedures: Minimally invasive techniques such as glycerol injection, radiofrequency thermal lesioning, or balloon compression that selectively damage the trigeminal nerve to block pain signals. These methods provide immediate relief but may lead to facial numbness and pain recurrence over time.
Peripheral Nerve Stimulation: Implantation of small electrodes near trigeminal nerve branches to deliver mild electrical impulses, interrupting pain signals. This technique may be considered when other treatments have not provided relief or for patients unable to tolerate more invasive procedures.

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Prevention and Management

Trigeminal neuralgia cannot be entirely prevented, but certain strategies help manage symptoms. Avoiding personal triggers such as specific foods, excessive talking, or wind exposure may reduce attacks. Maintaining a consistent medication schedule supports stable drug levels. Stress management techniques, including meditation, gentle yoga, or cognitive behavioural therapy, may help reduce attack frequency. Regular follow-ups with healthcare providers allow for timely treatment adjustments.

Frequently Asked Questions (FAQ)

How is trigeminal neuralgia different from other facial pain conditions?

Trigeminal neuralgia causes sudden, electric shock-like pain along the trigeminal nerve branches. Pain occurs in brief, intense episodes triggered by light touch or routine activities. In contrast, conditions like temporomandibular joint disorder or migraines typically cause more continuous, dull, or throbbing pain.

Can trigeminal neuralgia resolve on its own?

While pain-free periods may last months or years, complete spontaneous resolution is rare. The condition usually recurs, with remissions becoming shorter over time. Some patients achieve extended relief with appropriate treatment.

Can dental work trigger trigeminal neuralgia?

Yes, dental procedures can sometimes trigger pain episodes, but they do not cause trigeminal neuralgia. In some cases, patients may mistake their symptoms for dental problems, leading to unnecessary extractions or treatments before an accurate diagnosis is made.

Dr. Teo Kejia

Senior Consultant Neurosurgeon

MBBS (Singapore)|MRCS (Edinburgh)|FAMS (Neuro.Surg)|FRCS Ed (Neuro.Surg)|IFAANS

Dr. Teo’s expertise lies in complex brain tumour surgeries employing advanced techniques like brain mapping and awake brain surgery. He also manages neurovascular conditions, traumatic head injuries and spinal disorders.

Dr. Teo graduated from the National University of Singapore with a Bachelor of Medicine and Bachelor of Surgery in 2006. He completed his general surgery training and advanced neurosurgery training at the National University Hospital Singapore. He furthered his education in the United Kingdom, obtaining advanced certifications and completing specialist training in various neurosurgical disciplines.
Dr. Teo’s AMDA award facilitated his training at Queen’s Hospital in London, where he specialized in functional neurosurgery, neuro-oncology, neurovascular, skull base, and spinal surgery. He also underwent fellowship training in brain mapping and awake brain surgery at renowned institutions in Italy and France, working with leading experts in the field.

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