Trigeminal Neuralgia & Facial Pain

A Complex and Acutely Painful Condition

Trigeminal neuralgia, while a rare disorder, is one of the more commonly heard of facial pain disorders. In 2021, “The Good Doctor” and “Chicago Med” both featured a patient with what is nicknamed “the suicide disease.” In both cases, they had successful microvascular decompression surgery performed leaving many to wonder if this is the obvious way to treat this often disabling pain. While this may be the case for some, it is certainly not the whole story. The trigeminal nerve plays a vital role in migraine and headache diseases making it important for patients to understand what it is and how it may affect migraine. If you experience facial pain, this is an important conversation to have with your healthcare providers.

Where Is The Trigeminal Nerve?

The trigeminal nerve is a pair of nerves that starts near the top of the ear and then branches out into 3 sections of the face. It is because of these 3 branches that it received its name: TRIgeminal. The trigeminal nerve is the 5th and most complex cranial nerve (known as “V”) and is responsible for providing sensation to the face. There are two sets of each cranial nerve, and the one on the left does not connect to the one on the right. As a result, trigeminal neuralgia causes unilateral pain in the face. Unfortunately, the trigeminal nerve is the longest cranial nerve and is the most common one to cause nerve pain.

The 3 branches of the trigeminal nerve each impact a different part of the face:

• Branch 1 (known as V1) is the ophthalmic branch of the trigeminal nerve. This covers the forehead, scalp, upper eyelid, bridge & sides of the nose.
• Branch 2 (known as V2) is the maxillary branch. This includes the lower eyelid, cheeks, maxillary sinus, nasal cavity, walls of nose, upper lip, upper teeth & gums, and the roof of mouth.
• Branch 3 (known as V3) is the mandibular branch of the trigeminal nerve. This sends nerve signals to the floor of the mouth, external ear, lower lip, chin, front ⅔ of the tongue, lower teeth and gums.

What Does It Feel Like?

Trigeminal Neuralgia is also called “tic douloureux.” Tic Douloureux means painful muscle twitch. Classical trigeminal neuralgia (TN1/Typical TN) are sharp stabbing pains that last a fraction of a second to about 2 minutes each. The pain is primarily in the V2 & V3, with the forehead (V1) being unusual. The pain is unilateral and is often referred to as a “lightning strike” or a “shock”. Typically this type of trigeminal neuralgia is caused by a compression of the trigeminal nerve by a vessel, and the good news is that there are typically times of remission.

Classical TN with concomitant continuous pain (TN2/Atypical TN/ATN) is more of persistent dull ache and/or burning sensation. This pain can get worse over time and the cause and treatment is much more complex in this condition. While there can be sharp pain also, there often is not a specific trigger point for the pain.

Parasympathetic Autonomic System

The trigeminal nerve isn’t just about pain, it can also trigger the parasympathetic autonomic system. This can create extra symptoms such as crying and salivating. The eye(s) may tear, droop and/or redden. The nose may become runny and/or congested, and there can even be excess saliva which results in drooling.

How Can I Manage The Pain?

There are medications and treatments that have been successful in helping patients manage TN better, so it’s important to work with your healthcare provider. Talking with your health care provider to see which treatments you may benefit most from and discussing the possible side effects will help you decide which path to take. Some options include:

• Sodium channel blockers such as carbamazepine and oxcarbazepine (most commonly tried first)
• Tricyclic antidepressants
• Baclofen
• Some of the new migraine medications
• Microvascular decompression surgery (for TN1)
• Other invasive treatments (for TN1 and TN2)

Triggers

One of the hallmarks of trigeminal neuralgia is pain that is triggered by touch. As a result, attacks can be triggered by activities that most of us take for granted, such as:

• Touching the skin lightly
• Washing
• Shaving
• Brushing teeth
• Blowing the nose
• Drinking hot or cold beverages
• Encountering a light breeze
• Applying makeup
• Smiling
• Talking

It is important to keep in mind that all other diagnoses should be ruled out before giving this diagnosis, so please don’t self-diagnose, but rather talk with your doctor! Sometimes conditions such as multiple sclerosis can cause secondary trigeminal neuralgia. Other conditions such as post-traumatic neuropathy or herpes zoster can cause neural damage. It is very important to consider all these things when looking for a diagnosis and considering treatment options. If this information helps you make sense of your situation, having a conversation with your doctor can be a helpful place to start, and especially a facial pain specialist who is educated in conditions such as trigeminal neuralgia.

Let Us Know

Do you experience trigeminal nerve pain during your migraine or other headache attacks? Does facial pain trigger migraine attacks for you, or vice versa? Have you had a conversation with your doctor about this, and how do you manage these symptoms?