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Anyone who has lived through a root canal knows there are few experiences more excruciating than facial pain. People with trigeminal neuralgia—damage to the nerve that communicates facial sensations to the brain—live with the constant threat of brief, stabbing facial pain that can strike anytime. Fortunately, healthcare professionals have an arsenal of medications and surgical techniques that can reduce or eliminate pain for many patients, making a normal life possible.
What is trigeminal neuralgia?
Trigeminal neuralgia (TN) is a nerve condition characterized by recurrent bouts of sudden, stabbing, and brief facial pain. Minor sensations such as cold, wind, eating, touching the face, or talking can trigger these pain attacks. They can recur regularly for several weeks and then be followed by weeks, months, or years with no pain whatsoever.
Also called tic douloureux, trigeminal neuralgia results from the squeezing of the trigeminal nerve near its root in the skull. The trigeminal nerve (or cranial nerve V) emerges from the skull as a single nerve, but branches out into three major nerves that provide sensation and movement to the forehead, eyes, upper jaw, nose, and lower jaw. The pressure on the nerve root damages the protective myelin sheath around the nerve as well as outer nerve fibers. Vibrations or contact trigger irritation where the nerve is damaged, and the irritation generates misfired impulses, radiating pain to parts of the face.
In most cases—80% to 90%—the nerve damage is caused by a blood vessel compressing the trigeminal nerve as it exits the skull. Called classic or idiopathic trigeminal neuralgia, the condition is primarily treated by antiepileptic drugs or surgery. Sometimes, however, an underlying condition such as a tumor, cyst, or multiple sclerosis is the culprit, a condition called symptomatic or atypical trigeminal neuralgia. Treatment will focus on the underlying problem.
How is trigeminal neuralgia diagnosed?
Trigeminal neuralgia is usually diagnosed based on the patient’s symptoms. Most patients bring the problem to a general practitioner or emergency room physician, but the final diagnosis and treatment will be made by a neurologist.
The characteristic symptom of trigeminal neuralgia is mild to severe stabbing facial pain that is:
- Sudden and shock-like
- Brief (lasting seconds to minutes)
- Usually occurring on one side of the face
- Comes and goes
- Is often triggered by minor facial sensations such as touching the cheek, vibrations, cold, wind, brushing teeth, eating, or talking
Aside from a medical history, the doctor will perform a physical examination of the head and neck, as well as a neurological examination. Generally, the neurologic examination is normal in a patient with classical trigeminal neuralgia, but upon physical exam it would assist in verifying a diagnosis if specific trigger zones were identified. Some reflex tests, such as loss of corneal reflex in the eye (blinking) or weakness in any of the facial muscles might point toward a diagnosis of symptomatic trigeminal neuralgia.
If a patient history reveals the pain is moderate but never goes away, a more serious condition such as multiple sclerosis or tumor may be the cause. Magnetic resonance imaging (MRI) using contrast dye will be used to scan the head as part of any diagnostic work-up. The purpose of the MRI is to exclude secondary causes from a diagnosis of classic trigeminal neuralgia, or in preparation for surgery in the management of classic trigeminal neuralgia.
Trigeminal neuralgia treatment options
Trigeminal neuralgia is initially treated with medications. If medical therapy doesn’t work, surgical options are available to provide relief from flare-ups.
Medications
Antiepileptic drugs (AEDs), also called anticonvulsants, are the first-line therapy for trigeminal neuralgia. These drugs work by interfering the transmission of overactive pain signals, but they also have serious side effects. A neurologist may also prescribe baclofen, a muscle relaxant, to reduce the anticonvulsant dose. If one drug doesn’t work, neurologists will try other antiepileptic drugs, antidepressants, or anesthetics. Many of these therapies are unproven, but they may work for some patients.
Surgery
Medical treatment of trigeminal neuralgia may fail for several reasons: the drugs may not work, their effectiveness may wear off after time, or the side effects may be too hard to live with. As many as half of trigeminal neuralgia patients eventually undergo some form of surgery. Many will experience significant pain relief for anywhere from one to several years. Surgical treatments aim to either relieve the pressure on the nerve or to selectively damage nerve fibers that communicate pain signals.
- Microvascular decompression (MVD) provides the most sustained pain relief but is the most invasive neurosurgical procedure for trigeminal neuralgia. A neurosurgeon moves the blood vessel that is squeezing the trigeminal nerve, essentially fixing the cause of the problem. The procedure is performed under general anesthesia,requires a hospital stay, and does come with risks of serious complications. However, the success rate is high.
- Percutaneous rhizotomy is often used in patients with trigeminal neuralgia that may not be good candidates for the more invasive microvascular decompression procedure due to age or other conditions. . In these procedures, the trigeminal nerve is partly injured just where it emerges from the skull. The surgeon inserts a device or hollow needle through the skin and uses heat (radiofrequency lesioning), chemicals (glycerol injections), or mechanical means (balloon compression) to destroy pain fibers while preserving other nerve fibers.
- Gamma Knife radiosurgery (GKRS) is not technically surgery. Nothing is actually cut. The Gamma Knife device precisely aims a high dose of high-energy radiation right where the trigeminal nerve exits the skull. After treatment, nerve cells slowly die off over the next several months. As they die off, the pain signals get “scrambled” and stop making it to the brain. Therefore, the pain relief from this procedure is not immediate, but the procedure is done on an outpatient basis and provides several years of pain relief in four out of five patients. With this procedure, there is a risk that nerve connections may regrow.
Trigeminal neuralgia medications
There are only three “proven” drugs used to treat trigeminal neuralgia: carbamazepine, oxcarbazepine, and baclofen. They do not work for everyone, and many patients may not be able to endure the side effects. If that happens, a neurologist may prescribe other drugs that have worked in some patients. Except for carbamazepine, all are prescribed off-label, and doses can vary greatly from patient to patient.
Anticonvulsants
The only drug solidly proven to provide pain relief for trigeminal neuralgia is carbamazepine, an anti-epileptic drug (AED) normally prescribed to patients who have seizures. Also called anticonvulsants, drugs like carbamazepine prevent seizures by blocking repetitive excitatory electrical signals that travel down the length of nerves. Carbamazepine, however, can produce serious side effects and may gradually lose effectiveness over time. A neurologist may then prescribe a similar anticonvulsant called oxcarbazepine. Other anticonvulsants, such as lamotrigine, topiramate, or valproic acid, may alsobe tried if first-line therapy doesn’t work.
For trigeminal neuralgia, gabapentin, and pregabalin, drugs commonly prescribed for nerve pain, are often the second-line therapy of choice. They can provide effective pain relief with fewer side effects than other anticonvulsants. As a last resort, a neurologist may prescribe clonazepam, an anticonvulsant that works much the same way as gabapentin. It can control trigeminal nerve pain in some patients but has serious side effects including sedation and dependence.
The problem with anticonvulsants is that they have to be swallowed, but some patients may be in too much pain to swallow a pill. In those cases, a neurologist or emergency room physician may use intravenous anticonvulsants such as phenytoin, fosphenytoin, or levetiracetam to provide immediate pain relief.
Baclofen
Baclofen is a skeletal muscle relaxant that is primarily used to treat moderate to severe back pain. However, it doesn’t relieve trigeminal neuralgia as a muscle relaxant. Instead, baclofen reduces a chemical, called Substance P, in the central nervous system that’s essential to transmitting pain signals. Baclofen is a proven therapy for trigeminal neuralgia, but other muscle relaxants are not. It is often prescribed to enhance the effects of carbamazepine to allow for lower doses and fewer side effects.
Botulinum toxin injection
Botulinum toxin A, better known as Botox, paralyzesnerves. A small amount is injected near the roots of the upper jaw and lower jaw branches of the trigeminal nerve. The goal is to neutralize the pain fibers while preserving the other nerve fibers. Studies have shown that most people with trigeminal neuralgia experience significant pain relief for weeks or months after a botulinum toxin injection, so some neurologists will use it as an alternative to surgery.
Other medications
Aside from carbamazepine, oxcarbazepine, and baclofen, the American Academy of Neurology (AAN) considers all other trigeminal treatments as “unproven.” To avoid surgery, neurologists may try additional classes of drugs including antidepressants (sumatriptan or amitriptyline) and anesthetics (capsaicin).
What is the best medication for trigeminal neuralgia?
While only a few drugs are proven effective for trigeminal neuralgia, neurologists rely on a number of drugs because not all medications work for everyone. Patients may need to try several different medications, so there is no “best” medication for trigeminal neuralgia.
| Best medications for trigeminal neuralgia | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Tegretol (carbamazepine) | Anticonvulsant | Oral | 100mg to 200mg twice daily and titrated to effect with a maximum total dose of 1200mg per day in divided doses | Sedation, dizziness, nausea |
| Trileptal (oxcarbazepine) | Anticonvulsant | Oral | 150mg twice daily titrated to effect with a maximum total dose of 1800mg per day in divided doses | Dizziness, sleepiness, fatigue |
| Lioresal (baclofen) | Muscle relaxant | Oral | 10mg once daily titrated to effect with a maximum total dose of 80mg per day in three to four divided dose | Drowsiness, dizziness, weakness |
| Lamictal (lamotrigine) | Anticonvulsant | Oral | 25mg twice daily titrated to effect with a maximum total dose of 400mg per day in 2 divided doses | Dizziness, headache, double vision |
| Dilantin (phenytoin) | Anticonvulsant | Intravenous infusion | Dosing dependent upon weight | Injection site reactions, dizziness, drowsiness |
| Neurontin (gabapentin) | Anticonvulsant | Oral | 300mg once daily titrated to effect with a maximum daily dose of 1800mg per day | Headache, eye problems, coordination problems |
| Botox (botulinum toxin A) | Neurotoxin | Injection | 25 to 75 units (varies) | Pain, temporary facial imbalance, temporary swelling |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of trigeminal neuralgia medication?
Trigeminal neuralgia medications frequently produce unwanted side effects, but different classes of medications have different side effects. This is not a complete list, so please consult with a healthcare professional for possible side effects and drug interactions based on your specific situation.
Anticonvulsants can dramatically relieve trigeminal neuralgia, but they work by slowing down the nervous system. Common side effects include sleepiness, weakness, fatigue, confusion, dizziness, memory problems, vision problems, tremor, and loss of balance or coordination. The most serious side effects are potentially lethal allergic reactions.
Like anticonvulsants, baclofen, a muscle relaxant, works by slowing down the nervous system. Again, drowsiness, dizziness, sleepiness, confusion, and low blood pressure are common side effects. Baclofen can cause withdrawal symptoms such as hallucinations and seizures if the medication is discontinued abruptly.
Botulinum toxin typically has minor side effects such as redness and swelling. Since the injection affects nerves on one side of the face, the face may appear imbalanced or asymmetric for a few days. The most serious risk with botulinum toxin is spreading to other parts of the body and damaging nerves in other parts of the body.
What is the best home remedy for trigeminal neuralgia?
No home remedy works for everyone with trigeminal neuralgia, but there are a few tried and proven ways to help manage the pain while waiting for treatment or getting through the recovery period.
Avoid triggers
The best way to manage attacks is to avoid them in the first place. Not everyone is triggered in the same ways, so know your triggers and avoid them. You can start by keeping a symptom diary. Note when the pain starts, how long it lasts, and what you were doing right before the flare-up. You may be able to spot a whole cluster of possible triggers.
Use heat
Some patients find relief—sometimes total relief—with a warm or hot compress, hot water bottle, or warm washcloth applied directly to the affected area for 10 minutes. Many patients report that the compress must be very hot, but not so hot as to be intolerable. A few minutes in a hot shower or sauna might also help.
Use cold
If heat doesn’t work, a cold pack or compress placed on the affected area for 10 to 15 minutes has helped some patients. For some people, however, cold is a trigger, so a cold compress may make the pain worse.
Use heat and cold
A commonly advised home remedy that works for some people is to apply a cold compress to the carotid area of the neck—to reduce blood flow to the face—and a hot compress to the affected part of the face to calm the nerve. Some people find relief by alternating hot and cold compresses to the face.
Apply pressure to the face
Place your hand directly over the upper and lower jaws on the side of the face that hurts and press. It may take a great deal of pressure and may only partially relieve the pain, but it does work in some people.
Apply topical anesthetics
Some patients apply topical anesthetics such as camphor, lidocaine, or benzocaine cream, or lotion to numb the face to prevent triggering a flare-up.
Frequently asked questions about trigeminal neuralgia
Are there any new treatments for trigeminal neuralgia?
Some new treatments for trigeminal neuralgia are becoming more common. Stereotactic radiosurgery uses small beams of radiation to eliminatetrigeminal nerve fibers that transmit pain. A number of clinics stimulate peripheral nerves or the brain with electricity to provide pain relief, but these therapies have not been demonstrated as effective.
Can trigeminal neuralgia be cured?
Trigeminal neuralgia cannot be cured, but medications or surgery might be able to permanently alleviate pain or prevent flare-ups. Both have a high rate of success in relieving pain and restoring a high quality of life.
Can trigeminal neuralgia go away by itself?
In many patients, trigeminal neuralgia may go into remission for months or years between flare-ups. It doesn’t mean the condition has “gone away,” because future flare-ups are always possible.
What causes trigeminal neuralgia to flare up?
Trigeminal neuralgia flare-ups are typically caused by minor facial sensations such as cold, touch, chewing, washing, tooth brushing, or talking. These minor, painless sensations irritate the trigeminal nerve where it is damaged near its root. This irritation radiates as blinding pain down the branches of the trigeminal nerve.
What is the best treatment for trigeminal neuralgia?
The proven treatments for trigeminal neuralgia are the anticonvulsants carbamazepine and oxcarbazepine as well as the muscle relaxant, baclofen. Surgery has a high success rate in relieving pain for several years, but it is reserved only when medical therapy has failed.
What can trigger trigeminal neuralgia?
Trigeminal neuralgia is triggered by minor and painless facial sensations which, when they pass through the trigeminal nerve, cause irritation at the spot where the nerve is damaged. This irritation produces the sometimes overwhelming bolts of pain typical of a trigeminal neuralgia flare-up.
What are the side effects of CyberKnife treatment for trigeminal neuralgia?
Many patients will feel a little bit of pain for a few days because of the pins used to fasten the Gamma Knife frame to the head. The most common side effect of radiosurgery is facial numbness and tingling. Headache, nausea, and vomiting are also common side effects.
What vitamins are good for trigeminal neuralgia?
Vitamins such as vitamin D and B12 are often advised as “good” for trigeminal neuralgia. However, the condition is not a nutrient-deficiency related problem, but, in most patients, a mechanical one. Supplements are worth a try, but they haven’t been shown to have any effect on preventing or moderating flare-ups.
What foods trigger trigeminal neuralgia?
Some people report that certain foods trigger trigeminal neuralgia attacks, but triggers vary from person to person. Trigeminal neuralgia is not a dietary condition, but a mechanical one. In order to find what triggers attacks, keep a symptom diary. Note down when you experience flare-ups, how long they last, where you feel pain, and what you were doing immediately before the attack. The diary will help you identify triggers unique to your condition.
How do you calm down trigeminal neuralgia?
In the same way that many people have different triggers for trigeminal neuralgia, a surprising number of home remedies work for some people but not others. Applying heat, cold, both heat and cold, breathing steam, applying pressure to the face—these all may help or they may not. Nerves can be a mystery, so you never know what might work.
Related resources for trigeminal neuralgia
- Facial Pain Association
- Trigeminal Neuralgia American Family Physician.
- Trigeminal Neuralgia Family Doctor.
- Trigeminal Neuralgia StatPearls
- Trigeminal Neuralgia: Summary of Evidence-based Guideline for Patients and their Families