About Trigeminal Neuralgia

Trigeminal Neuralgia (TN), also called tic douloureux, is a debilitating facial pain syndrome, that causes multiple sudden attacks of lancinating (stabbing or piercing) pain on the face. People often can be misdiagnosed and spend years of their lives in exquisite pain, without any clear explanation of what is causing their suffering. It is not unusual for a person with Trigeminal Neuralgia to visit many doctors – undergoing multiple needless dental procedures and other surgeries – before finally getting the correct diagnosis and the potential for relief.

As a neurologist specializing in the diagnosis and treatment of severe facial pain syndromes, Dr. Ament has helped accurately diagnose and treat numerous patients with Trigeminal Neuralgia. His unique experience and skills increase their chances at a positive outcome.

What is Trigeminal Neuralgia?

Also called “tic douloureux” (literally “painful twitch”), it is a painful nerve disorder that affects the trigeminal nerve, which carries sensation from the forehead, cheek and lower jaw, to the brain. It is characterized by very brief, sudden attacks of lancinating pain on one side of the face and can occur multiple times a day. 

Who Is Affected?

According to the National Institute of Neurological Disorder and Stroke (NINDS), approximately 150,000 people are diagnosed with TN every year. While the disorder can occur at any age, it is most common in people over the age of 50. It is more common in women, with a female-to-male ratio of 3:2.

What Are The Symptoms?

Trigeminal Neuralgia causes sporadic, sudden jolts of intense stabbing or electric-shock-like pain that lasts anywhere from a few seconds to as long as 2 minutes per attack. These attacks can occur in quick succession. The pain is located in the lower face, cheek and jaw, and is usually limited to one side of the face. Occasionally (~5%), pain may occur over the eye. The intensity of pain can be debilitating.

An episode of TN may start as short, mild attacks, but it can progress, causing more frequent attacks of searing pain. Even mild stimulation of the face – such as brushing your teeth or shaving – can trigger an attack.

In the days before an episode begins, some patients may experience a tingling or numbing sensation or a somewhat constant and aching pain. Following a painful paroxysm there is usually a refractory period during which pain cannot be triggered. The bouts of pain rarely occur at night, when the patient is sleeping. Because of the pain, some patients experience facial twitching or tic, which is why the disorder is also known as tic douloureux.

Trigeminal Neuralgia tends to run in cycles (also called episodes or bouts). Patients often suffer long stretches of frequent attacks followed by weeks, months or even years of little or no pain. While Trigeminal Neuralgia is not fatal, the intensity of the pain may cause some patients to avoid daily activities because they fear an impending attack.

What Are Its Triggers?

Triggers include such typical daily activities as:

  • Brushing teeth

  • Shaving

  • Applying makeup

  • Chewing

  • Washing

  • Lightly touching the face

  • Being exposed to wind

  • Speaking

  • Drinking

  • Eating

What Causes Trigeminal Neuralgia?

In Trigeminal Neuralgia, the trigeminal nerve’s function is disrupted, causing the syndrome described.

The most commonly identified cause of Trigeminal Neuralgia is due to contact between a healthy blood vessel and the trigeminal nerve as it exits the brain stem. The blood vessel, whose characteristics may change with normal aging, then places pressure on the nerve as it enters the brain and causes nerve malfunction.

Other causes of TN include Multiple Sclerosis (2-4%), tumors (posterior fossa meningiomas, neuromas, cholesteatomas, metastases), sphenoid sinusitis, and basilar artery aneurysms.

Doctors are more likely to find a cause in a person who is younger than age 40, and development of Trigeminal Neuralgia in a young adult suggests the possibility of multiple sclerosis.

“Classical” or “symptomatic” Trigeminal Neuralgia is the term used when no cause for the syndrome has been identified, or when it is caused by a blood vessel compressing the trigeminal nerve. When a cause other than blood vessel compression is identified, then it is referred to as “secondary” Trigeminal Neuralgia.

How is Trigeminal Neuralgia Diagnosed?

There is no single test to diagnose TN. The diagnosis is generally based upon the patient’s description and location of the pain, its triggers, and a thorough neurological examination.

In most cases, the neurological examination between attacks is normal. An MRI of the brain with and without contrast dye is often ordered. This allows the physician to evaluate for potential secondary causes of Trigeminal Neuralgia, such as multiple sclerosis and tumor.

Imaging of the vessels at the base of the brain may also be ordered, such as MR Angiography, CT Angiography, or conventional angiogram. These tests can assist in evaluating the presence of a blood vessel pressing on the trigeminal nerve.

If no vessel is identified, this does not rule out the possibility of compression. However, if the vessel can be identified, it provides further rationale for microvascular decompression as a treatment option.

Mimics of Trigeminal Neuralgia

Although all cases of Trigeminal Neuralgia are caused by irritation of the trigeminal nerve, not all trigeminal nerve irritations result in Trigeminal Neuralgia. Other possible diagnoses include:

  • Post-Herpetic Neuralgia (herpes zoster, shingles)

  • Pain after dental procedures with the development of a focal neuroma

  • Temporal tendinitis

  • Irritation of the Stylomandibular ligament (Ernest syndrome)

  • Focal nerve irritation/neuralgia from sinus disease or other causes (infraorbital neuralgia, Sluder’s neuralgia, anterior ethmoid neuralgia, pterygopalatine ganglion neuralgia, or sphenopalatine ganglion neuralgia)

How is Trigeminal Neuralgia Treated?

The exact treatment will depend upon the correct diagnosis. For cases of secondary Trigeminal Neuralgia – those caused by some other condition such as multiple sclerosis – the treatment will be directed at the underlying cause. For classical or symptomatic Trigeminal Neuralgia, there are a number of available medication options to lessen or block the sensitivity of the trigeminal nerve. These may be used singly, or in combination to achieve the desired effect.


  • Anti-convulsants (carbamazepine, oxcarbazepine, gabapentin, pregabalin, lamotrigine, phenytoin, and valproic acid)

  • Muscle relaxants (baclofen)

  • Benzodiazepines (clonazepam)

  • Tricyclic antidepressants (amitriptyline, nortriptyline)

Some patients may find the medications ineffective or the doses may cause unacceptable side effects such as excessive sedation. In these cases, pain blocks or surgery may be recommended. Examples of these procedures include:

  • Microvascular decompression (MVD) – surgery to move the blood vessel compressing the nerve.

  • Trigeminal nerve blocks

  • Rhizotomy – destruction of select nerve fibers by various techniques

  • Stereotactic radiosurgery (Gamma knife)

  • Radiofrequency ablation

  • Balloon microcompression

  • Glycerol injection

Some patients find additional benefit complementary techniques, usually in combination with medications. Options include:

  • Acupuncture

  • Biofeedback

  • Nutritional and supplement therapy

  • Electrical stimulation of the nerves

Expectations (Prognosis)

In Trigeminal Neuralgia, periodic remissions are common, but permanent remissions or cures are rare. In a majority of patients, relapses occur, often within six months. The course is variable and unpredictable. In the cases of secondary Trigeminal Neuralgia, the prognosis depends upon the underlying cause.

However, despite the severity and variability of the disorder, a diagnosis of Trigeminal Neuralgia doesn’t necessarily mean a life of pain. Although Trigeminal Neuralgia cannot always be cured, it can usually be well managed with a combination of medications, injections, or surgery.

When To See A Doctor

If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over-the-counter pain relievers, see your doctor.