Diagnosis
Your healthcare professional may diagnose trigeminal neuralgia mainly based on how you describe your pain. This person may ask you questions about your pain, including:
- Type. Pain caused by trigeminal neuralgia is sudden, intense and quick. It may feel like an electric shock. The pain may last for less than a second or up to two minutes.
- Location. Where you feel pain in your face can tell your care team if the trigeminal nerve is involved.
- Triggers. Eating, talking, a light touch or even a cool breeze on your face can bring on pain.
Your care team may do tests to help diagnose or find the cause of trigeminal neuralgia. Tests may include:
- A neurological exam. Touching and checking parts of your face can help your care team know where the pain is happening and which branch of the trigeminal nerve may be involved. Reflex tests can help show if your symptoms are caused by pressure on the nerve or another condition.
- MRI. You may need an MRI to look for possible causes of trigeminal neuralgia. An MRI may reveal signs of multiple sclerosis or a tumor. Sometimes a dye is injected into a blood vessel to show blood flow through the arteries and veins.
Your facial pain may be caused by many different conditions, so a correct diagnosis is important. To rule out other conditions, your healthcare team may order other tests.
Treatment
Choosing the right treatments for trigeminal neuralgia depends on the cause of your pain and many other factors. These include medical history, side effects, risks, how quickly treatments relieve the pain and how long pain relief lasts. There can be overlap in treatment options for the three different types of trigeminal neuralgia. But not all options are right for everyone.
Treatment options may include medicines, surgery, injections or other procedures. If trigeminal neuralgia is caused by another medical condition, such as multiple sclerosis, treatment may be needed for the underlying condition.
Medicines
Often, medicines are recommended as the first line of treatment for trigeminal neuralgia. Sometimes, no other treatment is needed. The following kinds of medicines are common choices to lessen or block the pain signals sent to the brain.
Antiseizure medicines. Most often, carbamazepine (Tegretol, Carbatrol, others) or oxcarbazepine (Trileptal, Oxtellar XR) are prescribed to treat trigeminal neuralgia. These medicines are shown to be effective in stopping or reducing pain. Genetic testing may be recommended before starting carbamazepine. It is known to trigger a serious reaction in some people, mainly those of Asian descent.
If these medicines don't work for you, other choices may include gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica). Lamotrigine (Lamictal), phenytoin (Dilantin, Phenytek, Cerebyx) or topiramate (Qudexy XR, Topamax, others) may be prescribed as well.
Your care team may increase the dose or switch to another type if these medicines become less effective over time. Side effects of antiseizure medicines may include dizziness, confusion, drowsiness and nausea.
- Muscle relaxants. Muscle-relaxing medicines such as baclofen (Gablofen, Fleqsuvy, others) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness.
- Botox injections. Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medicines. However, more research needs to be done before this treatment is widely used for this condition.
- Pain relievers. During episodes of pain, lidocaine may be used on its own or with other medicines to offer relief. Results tend to be best when lidocaine is used along with another treatment. Lidocaine is available as an aerosol that can be sprayed into the nose or mouth. Also, it can be injected directly into the area where pain is felt. Or it can be given intravenously (IV). This means it is injected into the bloodstream. Lidocaine treatments often need to be repeated.
Surgery
If medicines don't work, and your pain is caused by a blood vessel pressing on your trigeminal nerve, surgery may be recommended. The surgery for trigeminal neuralgia is called microvascular decompression (MVD). MVD is shown to be most effective for long-term pain relief, although it may come with serious risks.
During MVD, a surgeon moves or removes blood vessels that touch the trigeminal nerve to stop the pain from happening. A cut, known as an incision, is made behind the ear on the side where you feel the pain. Then the surgeon makes a small hole in your skull. This procedure is known as a craniotomy. Through this hole, the surgeon moves any arteries that are in contact with the trigeminal nerve. Finally, a soft cushion is placed between the nerve and the arteries.
If a vein is pressing on the nerve, the surgeon may remove it. Part of the trigeminal nerve may be cut if arteries aren't pressing on the nerve. This is known as a neurectomy.
Microvascular decompression can stop or reduce pain for many years. Long-term pain relief depends on the location of pain, type of pain and age of the person. Only a small number of people may have pain come back 3 to 5 years after surgery.
Risks of MVD include hearing loss, stroke, facial weakness, numbness or other complications. Most people who have this procedure have no facial numbness afterward.
Radiation
If MVD is not the right option for you, radiation treatment may help. Brain stereotactic radiosurgery, also known as Gamma Knife, is a noninvasive procedure to treat trigeminal neuralgia. Noninvasive means the procedure does not involve cutting into the body or making openings in the skin.
During Gamma Knife, a surgeon aims a focused dose of radiation at the root of the trigeminal nerve. The radiation damages the trigeminal nerve to reduce or stop pain. It may take up to a month after treatment before pain relief is felt.
Although pain relief may be slow to start, brain stereotactic radiosurgery is successful at stopping pain for most people. Like all procedures, there is a risk that pain may come back, often within 3 to 5 years. If pain returns, the procedure can be repeated or you may have a different procedure.
Common side effects of Gamma Knife include facial numbness. This may occur months or years after the procedure.
Rhizotomy
Rhizotomy might be recommended as another treatment if other options don't work or aren't possible. Rhizotomy is a minimally invasive procedure to treat trigeminal neuralgia. Minimally invasive means that only very small cuts are needed compared with regular surgery. These procedures often involve less pain and have faster recovery times.
In a rhizotomy, your surgeon destroys nerve fibers to reduce pain. This can cause some facial numbness. Types of rhizotomy include:
Glycerol injection. In this treatment, a needle goes through the face into an opening at the base of the skull. The needle is guided to a small sac of spinal fluid that surrounds the area where the trigeminal nerve divides into three branches. Then a small amount of sterile glycerol is injected. Glycerol is a clear, thick alcohol that damages the part of the trigeminal nerve that carries pain signals. This controlled injury blocks pain signals.
This procedure often relieves pain. However, pain returns in some people. Many people experience facial numbness or tingling after a glycerol injection.
Balloon compression. In this procedure, a hollow needle passes through the face. It is guided to a part of the trigeminal nerve that goes through the base of the skull. Then a thin, flexible tube called a catheter with a balloon on the end is threaded through the needle. The balloon inflates with enough pressure to damage the trigeminal nerve and block pain signals.
Balloon compression successfully controls pain in most people, at least for a period of time. Most people who have this procedure have some facial numbness for a brief time.
Radiofrequency thermal lesioning. This procedure destroys certain nerve fibers known to cause pain. While you're sedated, your surgeon inserts a hollow needle through your face. The needle is guided to a part of the trigeminal nerve that goes through the base of the skull.
Once the needle is in place, your surgeon briefly wakes you from sedation. An electrode is passed through the needle, which sends a mild electrical current through its tip. Your surgeon will ask you to say when and where you feel tingling.
When your surgeon finds the part of the nerve causing your pain, you're returned to sedation. Then, the electrode is heated until it damages the nerve fibers. This creates an area of injury known as a lesion. If the lesion doesn't stop your pain, your surgeon may create more lesions.
More Information
Alternative medicine
New and alternative treatments for trigeminal neuralgia haven't been as well studied as medicines or surgical procedures. Often, more research is needed to support their use.
However, some people have found improvement with treatments such as low-intensity pulsed ultrasound (LIPUS), acupuncture, biofeedback, chiropractic, laser, and vitamin or nutritional therapy. But these treatments are new or experimental, and results are still being studied. Be sure to check with your care team before you try an alternative therapy because it may interact with your other treatments.
Also, your care team may recommend other self-care methods to help support you through the pain of trigeminal neuralgia. Although these techniques may not treat the nerve directly, they may offer some relief. These methods may include relaxation training, mindfulness and meditation techniques, music, and cognitive therapy.
Coping and support
Living with trigeminal neuralgia can be hard. It can affect your interaction with friends and family, your productivity at work, and the overall quality of your life.
You may find encouragement and understanding in a support group. Group members often know about the latest treatments and tend to share their own experiences. If you're interested, your healthcare team may be able to recommend a group in your area.
Preparing for your appointment
Make an appointment with a member of your care team if you have symptoms of trigeminal neuralgia. After your initial visit, you may see a doctor trained in brain and nervous system conditions, known as a neurologist.
What you can do to prepare
- Track your symptoms. Write down any symptoms you've been having, and for how long.
- Note your triggers. Note any triggers that bring on facial pain.
- List your medical history. Make a list of your key medical information. Include any other conditions for which you're being treated. Also include the names of any medicines, vitamins or supplements you're taking and the doses.
- Ask for support. Take a family member or friend along, if possible. Someone who comes with you may remember something that you missed or forgot.
- Write down your questions in advance. It can help you make the most of your time with your healthcare professional.
For possible trigeminal neuralgia, some basic questions to ask include:
- What's the most likely cause of my pain?
- Do I need any diagnostic tests?
- What treatment approach do you recommend?
- If you're recommending medicines, what are the possible side effects?
- Will I need treatment for the rest of my life?
- How much do you expect my symptoms will improve with treatment?
- Is surgery an option?
In addition to the questions that you've prepared, don't hesitate to ask any others that come up during your visit. Also ask questions if you don't understand something.
What to expect from your doctor
You're likely to be asked a number of questions. Being ready to answer them may give you more time to go over points you want to discuss further. Your healthcare professional may ask:
- What are your symptoms and where are they located?
- When did you first develop these symptoms?
- Have your symptoms gotten worse over time?
- How often do you experience periods of facial pain? Have you noticed if anything seems to trigger your facial pain?
- How long does facial pain typically last?
- How much are these symptoms affecting your quality of life?
- Have you ever had dental surgery or surgery on or near your face, such as sinus surgery?
- Have you had any facial trauma, such as an injury or accident that affected your face?
- Have you tried any treatments for your facial pain so far? Has anything helped?
- What side effects have you experienced from treatment?