Trigeminal Neuralgia (TN), also known as Tic Douloureux, is considered
by many to be the "most terrible pain known to man." The
electric shock-like pain generally is on one side of the face and is
spasmodic, coming in short bursts lasting a few seconds.
Several attacks can follow each other within minutes. There are
often trigger points, places on the face which, if touched, trigger
an attack.. Eating, shaving, applying makeup and talking can be
triggers. There can be periods of remission when pain is
completely absent. These periods of remission, which can last
days, weeks, months, even years, are unpredictable and without medical
treatment, the pain usually returns.
TN is a very rare condition. Statistics vary,
but TN occurs in approximately 150 per million people per year. Medical
literature notes this condition is rare for anyone under age 50
but in reality, TN is known to exist in many younger individuals
was described as early as the first century A.D. in the writings
of Aretaeus.. Early treatments included bloodletting and bandages
containing poisons such as arsenic, mercury, hemlock, cobra and bee
venom. An 18th century French surgeon, Nicolaus Andre coined the
condition "Tic Douloureux," which means "painful
Several syndromes are closely related to TN, but have specific unique features
as well. These include post-herpetic neuralgia, atypical facial pain
(ATFP), and TN resulting from multiple sclerosis (MS).
Although the distinctions tend to be fluid, these are discussed
There are some
relatively effective treatments for TN. Unfortunately, although some of
the treatments are becoming standard, there is no single treatment that
is effective for all victims.
Trigeminal Neuralgia is a disorder of the trigeminal nerve, one of
twelve pairs of cranial nerves on each side of the head.
The cranial nerves
control movement and sense pressure, touch, pain and temperature in the
head and neck. These twelve cranial nerves are numbered from 1 to 12
using Roman numerals - e.g. I II III IV V VI VII etc..
You have two
trigeminal nerves, one on the right side of your head and one on the
left. The trigeminal nerve, the largest cranial nerve can be seen
Since the trigeminal
nerve is the fifth cranial nerve, it is referred to as "V" in
medical literature. The word "trigeminal" derives
from the Latin word "tria" which means "three" and
from "geminus" which means "twin" and refers to the
fact that the trigeminal nerve has three distinct branches on each side
of the head. These branches are referred to as V1, V2, and V3. The
following table lists these branches and describes what areas each
TRIGEMINAL NERVE - Fifth Cranial Nerve
to see a picture
forehead and nose
teeth, gums and lip, the cheek, lower eyelid and the side of the
teeth, gums and lip
Transmits pressure, touch, pain and temperature signals to the
2. MOTOR: Controls movement.
For a more in
depth discussion of the trigeminal nerve, see
Got Some Nerve (12 of Them): The Trigeminal Nerve
Neurosciences Guide at about.com
exceptional, detailed anatomy tour of all aspects of the Trigeminal
written by Jeremy S. Melker, a medical
student at the University of
Florida. With complex interactive graphics, this is a site not to be
missed to gain insight into the complexity of the trigeminal nerve.
There are a number of causes of Trigeminal Neuralgia:
- Pressure of a
blood vessel on the root of the trigeminal nerve.
- Demyelinization of
the nerve. In rare instances (less than 3%), TN is a symptom of
Multiple Sclerosis which destroys the myelin sheaths protecting
nerve fibers. Trigeminal Neuralgia is rarely the first symptom of
Multiple Sclerosis and typically appears in advanced stages of MS.
- Pressure of
a tumor on the trigeminal nerve (rare)
- Physical damage to
the nerve caused by dental or surgical procedures,
injury to the face or infections.
- Unknown. Not all
cases seem to have a clear cause.
- There is some
speculation that some cases of trigeminal neuralgia may be
inherited. See references and more information at: OMIM™
Online Mendelian Inheritance in Man
TN pain is usually described as a sudden sharp electrical, shocking,
stinging, stabbing pain that lasts for several seconds and may repeat
many times over the course of the day. Usually only one side of the
face is affected with pain, but TN on both sides (bilateral TN) is known to
exist. TN pain is often triggered by certain
stimuli, such as touching the face, eating, talking, shaving, etc. These
triggers vary from person to person. The pain may last for days, weeks, or months and then may
disappear for months, even years.
Area of Pain
The area of facial pain is reflected by which of the three branches of
the trigeminal nerve is affected. From the brief "anatomy
lesson" above, we see that
V1 (Opthalmic) the
first branch affects the eye, forehead and nose.
V2 (Maxillary) the
second branch affects upper teeth, gum and lip, the cheek, lower
eyelid and the side of the nose.
the third branch affects lower teeth, gum, lower lip and jaw.
is an excellent picture of the three areas.
TN pain can involve
one or more branches of the trigeminal nerve.
In classic TN described in medical literature, the pain is extremely
sharp, throbbing, and shock-like. There is no facial numbness or
weakness. With classic TN pain, there are distinct periods of
remission, when there is no pain at all. Classic TN generally responds
well to Tegretol, an anti-convulsive drug used to treat seizure
One typical feature of TN is that it is rarely typical. For many TN
patients, the condition does not conform to the symptoms of
"classic" TN. In addition to the stabbing shock-like
pain, many victims experience various kinds of pain that they may
describe as throbbing, burning, crushing, pulsating, etc. For
some, there are no remissions from the pain. These
"atypical" forms of TN are often very difficult to treat.
A thorough medical exam and history of symptoms should be done
along with medical tests to rule out any serious medical problems.
These tests can include a CAT scan or MRI. In some cases,
high-definition MRI angiography (MRTA) of the trigeminal nerve and the
brain stem can identify where the nerve is compressed by a vein or
artery but more often than not, no cause is found for the pain. If the
pain is diminished with carbamazepine (Tegretol) treatment, this
is a positive indicator for a diagnosis of TN. A special MRI technique,
3-D volume acquisition, performed with contrast injection, can detect
80% of the time whether a blood vessel pressing on the trigeminal nerve
is causing TN pain.
However, up to now, no medical
test exists that clearly diagnoses all cases of TN. TN diagnosis should not be difficult, especially in cases of classic TN
where the symptoms are clear and distinct. Yet time
and again, TN patients have seen numerous medical professionals
and have had multiple dental procedures performed before a diagnosis is
made. Sometimes years, even decades pass before the patient is
diagnosed. In some instances, the diagnosis is missed
because the patient does not display "classic" TN symptoms but
this does not explain entirely why so many TN patients are misdiagnosed.
Initial treatment for TN is usually medication with cabamazepine
(Tegretol®) being the first drug of choice. Other
drugs such as baclofen
(Lioresal®) , clonazepam (Klonopin
®) and gabapentin
(Neurontin®) are often used alone or in combination. Trileptal, a drug
which was recently approved for use in the US, appears to have fewer
side-effects than Tegretol and is often effective in controlling TN
pain. When medication
fails, surgery may be considered. For an overview and in depth
description of treatments for TN see the FNR Treatment
1. Dorweiler, Bryce D., Trigeminal Neuralgia,
for Cranial Nerve Disorders
(11/01) website from this neurosurgery clinic features:
discussions of several cranial nerve disorders, their characteristics,
and surgical and non-surgical treatment options. Dr. Anthony M.
Kaufmann, neurosurgeon and Director of the Centre for Cranial Nerve
Disorders has authored the information presented on the
Excellent and extensive discussion of trigeminal neuralgia
Neuralgia Workshop: Opportunities for Research and Treatment,
September 14, 1999
Summary of a workshop focusing on understanding the current status
of TN research and to identify new avenues of research and
collaborations that might have an impact on treatments, diagnosis,
Show on Surgical Treatments for Trigeminal Neuralgia
Excellent presentation on TN and its treatments by Dr.
Good discussion of using MRI imaging to identify vascular
loops to help deciding whether MVD procedure is
appropriate. Also presents an interesting method of deciding on
surgical procedures based on a patient's age.
Treatment Trigeminal Neuralgia and Hemifacial Spasm
Albert L. Rhoton, Jr., MD, Chairman of the Department of
Neurological Surgery at the College of Medicine University of Florida
writes an excellent description of TN and Hemifacial Spasm along with
some of the best illustrations depicting TN pain and surgical
procedures we've seen.
A Description of TN.
A simple-to-read description written specifically for the FNR site by
Dr R. Wayne Hurt, M.D. The focus is on treatments
Another short but comprehensive introduction, written by Dr Roger
Melvill (neurosurgeon). Has somewhat a focus on surgical treatments.
A translation of an article written by Jakke Makela in Finnish for his
local MS Foundation magazine. Provides a short description of TN and
also its more atypical forms. However, please note that the article is
not written by a medical professional.
Treatment of TN.
Trigeminal Neuralgia - You
Are Not Alone
A user-friendly site by Debby Creps with excellent
information on TN, treatments, support resources and other information
of use to people searching for information on trigeminal neuralgia..
Trigeminal Neuralgia Resources
A Co-editor of Facial Neuralgia Resources
tells the story of her encounter with Trigeminal Neuralgia, her
successful Microvascular Decompression surgery and also provides
pointers to other TN resources.
Neuralgia - A Personal Narrative
Follow a 60 year old woman's experience with Trigeminal
Neuralgia and how she found relief for her pain.
Neuralgia: A Personal Perspective
A good description of one woman's experience with
microvascular decompression and the complications she experienced.