ConditionBrain & nerves
Trigeminal Neuralgia
Trigeminal neuralgia is a nerve pain condition causing sudden, severe, electric shock-like attacks of pain on one side of the face, usually in the cheek, jaw, teeth, gums or lips. Attacks last seconds to 2 minutes and are often triggered by light touch, chewing, talking, brushing teeth or a breeze. It is most often caused by a blood vessel pressing on the trigeminal nerve, and is more common in women and people over 50. Anti-seizure medicines such as carbamazepine help most people, and surgery can provide long-lasting relief.
Also called: Tic douloureux, TN, classical trigeminal neuralgia, trifacial neuralgia
At a glance
- What it is
- Recurrent attacks of brief, severe, electric shock-like pain along branches of the trigeminal nerve.
- Who gets it
- Usually over 50; about twice as common in women; younger people should be checked for multiple sclerosis.
- Triggers
- Light touch, chewing, talking, brushing teeth, shaving, cold wind.
- Causes
- Usually a blood vessel compressing the nerve; also MS, tumors, or no identifiable cause.
- Diagnosis
- Typical history; MRI to look for compression or other causes.
- Treatment
- Carbamazepine or oxcarbazepine first; other medicines; microvascular decompression, radiosurgery or percutaneous procedures.
When to get help
Call 911 or go to the ER
- Thoughts of suicide because of pain: call or text 988 (US) or call 911
- Sudden facial numbness or weakness with slurred speech, arm weakness or vision loss (possible stroke)
See a doctor within a day or two
- Facial pain with numbness, weakness of chewing or facial muscles, hearing loss or double vision (possible tumor or other cause)
- Severe, frequent attacks preventing you from eating or drinking
- Rash, fever, sore throat or easy bruising after starting carbamazepine
Book a routine appointment
- Repeated electric shock-like stabs of pain on one side of the face
- Facial pain under age 40, or pain on both sides
- Pain that is no longer controlled by medicine, or side effects such as drowsiness and unsteadiness
The trigeminal nerve
The trigeminal nerve (the fifth cranial nerve) carries sensation from the face. It has 3 branches:
- ophthalmic (V1): forehead, eye and scalp
- maxillary (V2): cheek, upper jaw, upper teeth, upper lip and side of the nose
- mandibular (V3): lower jaw, lower teeth, lower lip and chin
Trigeminal neuralgia most often affects V2 and V3, usually on the right side, and rarely V1.
Symptoms
- sudden, intense, stabbing, shooting or electric shock-like pain on one side of the face
- attacks lasting a fraction of a second to 2 minutes, often in rapid volleys
- triggered by light touch, talking, eating, drinking, brushing teeth, applying makeup, shaving or a breeze
- pain-free periods between attacks in classic cases, sometimes for weeks or months (remission)
- some people develop a constant background ache or burning in addition to attacks (atypical or with concomitant continuous pain)
- avoidance of eating, washing or talking, leading to weight loss and social withdrawal
People often first see a dentist, thinking the pain comes from a tooth, and some have unnecessary dental work.
Causes
Classical trigeminal neuralgia
A blood vessel, usually the superior cerebellar artery, presses on the trigeminal nerve root where it leaves the brainstem. The pressure wears away the nerve's insulating myelin, causing abnormal electrical signals.
Secondary trigeminal neuralgia
- multiple sclerosis: demyelinating plaques in the brainstem; may affect both sides
- tumors: such as acoustic neuromas or meningiomas
- arteriovenous malformations
Idiopathic
No cause is found on imaging.
Trigeminal neuralgia vs other facial pain
| Condition | Key features |
|---|---|
| Trigeminal neuralgia | Brief electric shocks, triggers, one side |
| Dental pain or abscess | Constant throbbing, hot or cold sensitivity, a specific tooth |
| TMJ disorder | Aching jaw pain with chewing, clicking, jaw tenderness |
| Postherpetic neuralgia | Burning pain after shingles, often V1 |
| Cluster headache | Severe pain around one eye for 15 to 180 minutes, red teary eye |
| Atypical facial pain | Constant, poorly localized aching |
Diagnosis
Diagnosis is based on the characteristic history. A neurologist will examine facial sensation, chewing strength, hearing and other cranial nerves. MRI with special sequences is recommended to look for blood vessel compression, MS and tumors, and helps plan treatment.
Treatment
Medicines
- carbamazepine: the first-line treatment and effective for most people initially. Side effects include drowsiness, dizziness and low sodium; rarely serious skin reactions, especially in people of Asian ancestry with the HLA-B*15:02 gene (testing is recommended before starting)
- oxcarbazepine: similar effectiveness, often better tolerated
- other options: baclofen, lamotrigine, gabapentin, pregabalin, phenytoin
- acute severe attacks: IV medicines or nerve blocks in hospital
Medicines may become less effective over time, or side effects may limit the dose.
Surgery and procedures
For pain not controlled by medicines or side effects that are too troublesome:
- microvascular decompression (MVD): open surgery behind the ear to move the blood vessel away from the nerve and place a cushion between them. Offers the longest-lasting relief, with many patients pain-free for years, and preserves facial sensation. Has the risks of brain surgery, including hearing loss.
- stereotactic radiosurgery (Gamma Knife): focused radiation to the nerve root; relief develops over weeks; may cause numbness
- percutaneous procedures: radiofrequency rhizotomy, glycerol injection or balloon compression through a needle in the cheek; quick relief, usually some numbness, may need repeating
Living with trigeminal neuralgia
- eat soft foods at room temperature
- use a soft toothbrush and lukewarm water
- protect your face from wind and cold with a scarf
- keep a pain diary to identify triggers and track response to treatment
- seek support for anxiety and depression, which are common with severe pain
Frequently asked questions
What does trigeminal neuralgia feel like?
It feels like sudden, intense electric shocks or stabbing pain on one side of the face, usually in the cheek, jaw, teeth or lips. Each attack lasts seconds to 2 minutes and is often triggered by light touch, talking or chewing.
What causes trigeminal neuralgia?
Most often, a blood vessel presses on the trigeminal nerve where it leaves the brainstem, damaging its insulation. Multiple sclerosis and, rarely, tumors can also cause it. Sometimes no cause is found.
What is the best treatment for trigeminal neuralgia?
Carbamazepine or oxcarbazepine are first-line and work for most people. If medicines fail or cause side effects, microvascular decompression surgery offers the longest-lasting relief; radiosurgery and needle procedures are alternatives.
Can trigeminal neuralgia go away on its own?
It can go into remission for weeks, months or occasionally years, but it usually returns and often becomes more frequent over time. Treatment controls the pain in most people.
Sources
This guide was written from current patient and clinical guidance, including:
- National Institute of Neurological Disorders and Stroke: Trigeminal Neuralgia
- American Academy of Neurology and European Federation of Neurological Societies: Practice parameter, diagnostic evaluation and treatment of trigeminal neuralgia
- International Headache Society: International Classification of Headache Disorders (ICHD-3), 13.1.1 Trigeminal neuralgia
- European Academy of Neurology: Guideline on trigeminal neuralgia (2019)
- Facial Pain Association: Patient resources