A real pain in the face: all about trigeminal neuralgia

Facial pain, also known as trigeminal neuralgia, is a chronic dysfunction of the trigeminal facial nerve. In this article, a consultant oral & maxillofacial surgeon explains what causes facial pain to occur, and how it can be solved.

What causes facial pain?

The trigeminal nerve is a nerve in the face that starts from the centre of the head in the brain and branches out into the eyes and forehead, nasal, and jaw and mouth areas, becoming the ophthalmic, maxillary, and mandibular nerves. The trigeminal nerve provides sensation to the face, as well as facilitating motor function. This allows us to move our eyes, chew, and feel pain and heat on our faces.

Facial pain caused by trigeminal neuralgia can be categorised into three main types:

• Classical trigeminal neuralgia, which is caused by direct pressure on the trigeminal nerve. This pressure could be due to an artery or a vein crossing over the nerve where it meets the brain stem, compressing it.
• Secondary trigeminal neuralgia, which is symptomatic of a prior medical condition, such as a tumour, cyst, injury or damage, or as a complication of multiple sclerosis.
• Idiopathic trigeminal neuralgia, which is when the cause of the facial pain is unknown.

What are the symptoms of trigeminal neuralgia facial pain?

The pain of trigeminal neuralgia feels very sharp and sudden, striking in episodes that can last up to two or so minutes. The pain may feel like an electric or icy shock and can be so unbearable that patients may be left hapless during an episode. After the main pain has subsided, there still may be aching or throbbing sensations. Episodes can repeat frequently within days, weeks or months at a time with little respite in-between, or the pain may go dormant for years at a time (in what is called remission).

Depending on how the nerve is impeded, pain typically only affects one side of the face, but it can happen on both. It can impact the upper half of the face, but is more commonly felt in the teeth, cheeks, and jaws (the maxillary and mandibular nerves).

The pain can be triggered by certain facial movements or by touching the face, such as talking, smiling, chewing, brushing teeth, grooming, or even as gentle a sensation as a breeze. Some patients may not even have a clear trigger and the pain occurs spontaneously.

This can impact the quality of life of patients, making them fearful and avoidant of regular tasks like hygienic maintenance, eating, and social activities. This can lead to emotional strain and intense stress that can develop into depression or anxiety, even leading to suicidal ideation as a way to be free from the agony.

How is facial pain diagnosed?

A patient complaining of facial pain will often go to a dentist first due to its common locality in the jaw and mouth. A dentist may conduct an X-ray with suspicions of a cracked tooth or an infection, but may fail to determine the true cause of the facial pain.

This means they may refer the patient to a GP or specialist, who will conduct further diagnostic scans and tests as needed. The doctor will rule out other conditions (like bone fractures) by asking questions regarding the pain episodes – such as duration, triggers, and where in the face it is felt – and likely order an MRI, which is one of the best scans for diagnosis trigeminal neuralgia, and what is the cause of it.

How is facial pain treated?

To treat facial pain, there are a variety of methods a patient can explore to manage pain.

Typical painkillers will not be potent enough to provide relief, so typically patients are prescribed anticonvulsants (used to treat epilepsy), which can help by slowing down the electrical activity between nerves, obstructing pain signals. In the UK, the only anticonvulsant that is licenced to treat facial pain is carbamazepine, and patients will be advised to take the medication twice a day initially, with a gradual increase to up to four times daily – however, its effectiveness can lessen over time.

For pain that is constant, or that has not responded to medicinal intervention, surgery can be an option. There are a variety of procedures that can be performed to address the issue, but they are very complex and may not be entirely successful.

Percutaneous procedures, where a needle is inserted into the cheek and through the skull to the nerve, as guided by an X-ray, can treat facial pain by purposely damaging the nerve to disrupt its functionality. This includes methods such as:

• Glycerol injections, where glycerol is injected to the base of the nerve where it forks into three, called the Gasserian ganglion
• Radiofrequency lesioning, where heat is passed through the needle
• Balloon compression, where a tiny balloon is passed through the needle and inflated around the Gasserian ganglion to compress it

The pain relief from any one of these procedures may not be permanent, even if they work at all. The damage to the nerve will also cause partial numbness or constant sensation of pins and needles to the face.

Other surgical options include:

• Stereotactic radiofrequency, where a concentrated dose of radiation targets the trigeminal nerve, with the results becoming apparent over time.
• Microvascular decompression, which is a major surgery where portion of the skull is removed to lessen pressure on the nerve (in cases of primary trigeminal neuralgia), and can provide the most stable, long-lasting relief, although there is still a chance of pain returning within 20 years.

If you are experiencing facial pain, consult with a specialist on Top Doctors today.