Trigeminal Neuralgia (Tic Douloureux)
What Is It?
also known as tic douloureux, is a painful disorder of a nerve in the
face called the trigeminal nerve or fifth cranial nerve. There are two
trigeminal nerves, one on each side of the face. They are responsible
for detecting touch, pain, temperature and pressure sensations in areas
of the face between the jaw and forehead.
have trigeminal neuralgia typically experience episodes of sudden,
intense, “stabbing” or “shocklike” facial pain. This pain can occur
almost anywhere between the jaw and forehead, including inside the
mouth. However, it usually is limited to one side of the face.
In some cases, the cause of trigeminal neuralgia is unknown. In many
people, however, the disorder seems to be related to a local irritation
of the trigeminal nerve, usually in the area of the nerve root deep
within the skull. In most cases, the source of this irritation is
believed to be an abnormal blood vessel pressing on the nerve. Less
often, the nerve irritation is related to a tumor that involves the
brain or nerves, or to a rare type of stroke. In addition, up to 8
percent of patients who suffer from multiple sclerosis (MS) eventually
develop trigeminal neuralgia as a result of MS-related nerve damage.
New cases of trigeminal neuralgia affect four to five out of every
100,000 people in the United States each year. It affects women slightly
more often than men, perhaps because the disease is most common in
older people and women live longer. In most cases, the first episode of
facial pain occurs when the patient is 50 to 70 years old. Although
infants, children and young adults may develop this disorder, it is rare
in people younger than age 40.
neuralgia causes episodes of sudden, intense facial pain that usually
last for two minutes or less. In most cases, the pain is described as
excruciating, and its quality is “sharp,” “stabbing,” “piercing,”
“burning,” “like lightning” or “like an electric shock.” In most cases,
only one side of the face is affected.
The pain of
trigeminal neuralgia is recognized as one of the most excruciating forms
of pain known. The pain often is triggered by nonpainful facial
movements or stimuli, such as talking, eating, washing the face,
brushing the teeth, shaving or touching the face lightly. In some cases,
even a gentle breeze on the cheek is enough to trigger an attack.
Approximately 50 percent of patients also have specific trigger points
or zones on the face, usually located somewhere between the lips and
nose, where an episode of trigeminal neuralgia can be triggered by a
touch or a temperature change. In some cases, a sensation of tingling or
numbness comes before the pain.
trigeminal neuralgia can vary significantly, and may occur in clusters,
with several episodes following in series over the course of a day. For
unknown reasons, trigeminal neuralgia almost never occurs at night when
the person is sleeping.
In addition to pain, some
patients simultaneously have a cheek twitch or muscle spasm, wincing, a
facial flush, a tearing eye or salivation on the same side of the face.
It is the facial muscle spasms that led to the older term, tic
douloureux (from French, tic means muscle twitch or spasm; douloureux
doctor will ask about your symptoms and your medical history, including
any history of multiple sclerosis, a condition that may cause similar
or even identical symptoms. To help rule out medical and dental
conditions that can mimic trigeminal neuralgia, the doctor also asks
whether you have a history of:
- Recent trauma to your face or teeth
- A recent tooth infection or root-canal treatment
tooth extraction on the same side as your facial pain — Sometimes a
tooth extraction can cause pain in the area of the missing tooth.
areas of painful facial blisters — Painful blisters can be a sign that
you have a viral infection involving your facial skin, such as herpes,
which is caused by the herpes simplex virus, or shingles, which is
caused by varicella zoster, the chickenpox virus. Facial pain can
persist for weeks after the blisters heal, especially in cases of
Next, your doctor will
thoroughly examine your head and neck, including the area inside your
mouth. The doctor also will do a brief neurological examination and
concentrate on feeling and muscle movements in your face. In almost all
cases of trigeminal neuralgia, the results of these examinations are
normal. If necessary, your doctor will order a magnetic resonance imaging
(MRI) or computed tomography (CT) scan of your head to check for
blood-vessel abnormalities, tumors pressing on your trigeminal nerve or
other possible causes of your symptoms.
will diagnose trigeminal neuralgia based on your symptoms, the
examination and test results. There is no specific test to confirm the
diagnosis of trigeminal neuralgia, so an important part of the diagnosis
is excluding other explanations for the symptoms. In some cases, the
doctor prescribes a brief course of carbamazepine (Tegretol and others),
which is used to treat trigeminal neuralgia. A good response to this
medication supports the diagnosis of trigeminal neuralgia.
neuralgia is unpredictable. For unknown reasons, many people experience
periods when the illness suddenly intensifies and produces repeated
painful episodes over the course of several days, weeks or months. This
period may be followed by a pain-free interval that can last for months
The type of treatment that you receive may
influence the duration of your symptoms. Some treatments carry a higher
risk that the symptoms will return.
Because the cause of trigeminal neuralgia is unknown, it cannot be prevented.
first treatment for trigeminal neuralgia usually is carbamazepine
(Tegretol and others). Carbamazepine is an anticonvulsant medication
that decreases the ability of the trigeminal nerve to fire off the nerve
impulses that cause facial pain. If carbamazepine is not effective,
other possible drug choices include phenytoin (Dilantin), baclofen
(Lioresal), gabapentin (Neurontin), lamotrigine (Lamictal), clonazepam
(Klonopin) and valproic acid (Depakene, Depakote). These may be taken
individually or in combination. One study found that when trigeminal
neuralgia is related to multiple sclerosis, misoprostol (Cytotec), a
medication usually prescribed to prevent stomach ulcers, may be
effective. Narcotic pain relievers, such as oxycodone (OxyContin) or
morphine (several brand names), may be recommended briefly for severe
episodes of pain. Some of these medications carry the risk of unpleasant
side effects, including drowsiness, liver problems, blood disorders,
nausea, dizziness, overgrowth of the gums and skin rashes. For this
reason, people taking any of these medications may be monitored with
frequent follow-up visits and periodic blood tests. After a few
pain-free months, your doctor may attempt to decrease the dose of the
medication gradually or discontinue it. This is done to limit the risk
of side effects and to determine whether your trigeminal neuralgia has
gone away on its own.
If medication does not stop
your pain or if you cannot tolerate the side effects of medication, then
your doctor may suggest one of the following treatment options:
(selective destruction of part of the trigeminal nerve) — In this
approach, a portion of the trigeminal nerve is inactivated temporarily
by using one of the following methods: a heated probe, an injection of
the chemical glycerol or a tiny balloon that is inflated near the nerve
to compress it. During the procedure a needle or a tiny hollow tube
called a trocar is inserted through the skin of your cheek. These
procedures provide immediate relief in up to 99 percent of patients, but
25 percent to 50 percent of people will have the problem return during
the next several years.
- Stereotactic radiosurgery
— This form of radiation therapy uses a linear accelerator or a gamma
knife to inactivate part of the trigeminal nerve. After your head is
positioned carefully in a special head frame, many tiny beams of
radiation are aimed precisely at the portion of the trigeminal nerve
that must be inactivated. Stereotactic radiosurgery is a fairly new
treatment option for trigeminal neuralgia, and its long-term success
rate is still being evaluated.
- Microvascular decompression of the trigeminal nerve
— In this delicate surgical procedure, a surgeon carefully repositions
the blood vessel that is pressing on your trigeminal nerve near your
brain. Because this procedure involves opening your skull, the ideal
candidate for this procedure is someone who is generally healthy and
younger than 65. Overall, the immediate success rate is approximately 90
percent, and 70 percent to 80 percent of patients have long-term
relief. Microvascular decompression may be effective for patients who
have not had success with one of the less-invasive surgeries.
When To Call A Professional
You should seek medical help immediately if you develop facial pain that fits the pattern of trigeminal neuralgia.
most cases, the prognosis is good. Approximately 80 percent of patients
become pain-free with medication alone. When medication fails or
produces unwanted side effects, other treatment options are available
and also have a high rate of success.
Last revised: December 7, 2007
by Sharon M. Smith, M.D.
All ArmMed Media material is provided for information only and is
neither advice nor a substitute for proper medical care. Consult a
qualified healthcare professional who understands your particular
history for individual concerns.
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