Tic Douloureux (Trigeminal Neuralgia)

Facial nerve pain

Tic douloureux or trigeminal neuralgia is a severe, stabbing pain to one side of the face. It stems from one or more branches of the trigeminal nerve. The trigeminal nerve supplies sensation to the face. It is considered one of the most painful conditions to affect people and the pain from this disease is reported as severe.

The pain usually lasts from a few seconds to a few minutes. It may be so intense that you wince involuntarily, hence the term tic. There is usually no pain or numbness between attacks and the muscles of the face are not affected.

Most people feel pain in their jaw, cheek, or lip on only one side of the face. Pain is usually triggered by a light touch to the face or mouth on the same side as the pain. The pain can be so severe that people during attacks can become afraid to talk, eat, or move.

• Although attacks can last for weeks or months, there are usually periods of months or even years that are symptom-free.
• The pain of tic douloureux is usually controlled with medications or surgery.
• Tic douloureux is generally a disease of middle age or later life. Women are affected more often than men. People with multiple sclerosis are affected much more frequently than the general population.

The main symptom of tic douloureux is a sudden, severe, stabbing, sharp, shooting, electric-shock-like pain on one side of the face. Because the second and third divisions of the trigeminal nerve are the most commonly affected, the pain is usually felt in the lower half of the face.

• The pain comes in intermittent episodes that last from a few seconds to a few minutes. There may be many episodes of pain per day. There is no pain between episodes.
• The flurry of pain episodes may last from a few weeks to a few months, followed by pain-free periods of months to even years. Unfortunately, the episodes become more frequent and more resistant to treatment with medications over time.
• The attacks of pain are often initiated by physical stimulation of a trigger point on the same side of the face as the pain. Trigger points can be anywhere on the face or in the mouth or nose. They are generally not in the same place as the pain. Stimuli that can initiate the pain include talking, eating, brushing the teeth, or even cool air on the face. There is no loss of taste, hearing, or sensation in someone suffering from tic douloureux.

The main symptom of tic douloureux is a sudden, severe, stabbing, sharp, shooting, electric-shock-like pain on one side of the face. Because the second and third divisions of the trigeminal nerve are the most commonly affected, the pain is usually felt in the lower half of the face.

• The pain comes in intermittent episodes that last from a few seconds to a few minutes. There may be many episodes of pain per day. There is no pain between episodes.
• The flurry of pain episodes may last from a few weeks to a few months, followed by pain-free periods of months to even years. Generally, the episodes become more frequent and more resistant to treatment with medications over time.
• The attacks of pain are often initiated by physical stimulation of a trigger point on the same side of the face as the pain. Trigger points can be anywhere on the face or in the mouth or nose. They are generally not in the same place as the pain. Stimuli that can initiate the pain include talking, eating, brushing the teeth, or even cool air on the face. There is no loss of taste, hearing, or sensation in someone suffering from tic douloureux.

Because the pain commons on so suddenly and so severely, patients should not hesitate to seek care with the first episode. Call your doctor when the prescribed medications are not controlling the pain, or if you develop new symptoms. Because tic douloureux is a pain-only syndrome, the development of new symptoms should be reported to your physician and may warrant additional evaluation.

Go to a hospital's emergency department if you experience symptoms such as fever, redness of your face, or dizziness. These symptoms may not be related to your condition and may signify another illness. If your prescribed medication is not relieving the pain and your doctor is not available for advice, go to the emergency department.

There is no single medical test to diagnose tic douloureux. The diagnosis is made based on the description of the pain, physical examination, and exclusion of other causes of facial pain.

• The pain of tic douloureux is unique. A history of bursts of shooting pain in one side of the face along with a trigger zone will give the doctor good clues as to the cause of your pain.
• The physical examination is normal in tic douloureux. If numbness, decreased hearing, dizziness, visual changes, or dysfunction of the muscles of the face is found, then other disorders may be considered. Additionally, other causes of facial pain such as a sinus infection, dental infection, or a jaw disorder, such as TMJ, can often be found by physical examination.
• Special x-ray images, such as a CT scan or MRI of the head, can look for other causes of facial pain. They can also help delineate blood vessels or tumors that might be pressing on the nerve and irritating it.

The primary treatment of tic douloureux is medication to control the pain. Surgery may be necessary when drug therapy is not effective or side effects from the medications are not tolerable.

Home Remedies

There are no effective home treatment remedies for tic douloureux. Treatment should be guided by a physician. The role of the doctor is to ensure the diagnosis, begin appropriate therapy, and coordinate any potential need for further consultation. In most cases, effective treatment will require only medications. Uncommonly, surgery will be recommended.

A number of medications are effective in helping control the pain of tic douloureux. The most commonly prescribed medications are anticonvulsants (seizure medications). Anticonvulsants help to stop the irritating trigeminal nerve from firing pain impulses.

• The most frequently prescribed anticonvulsant medication for tic douloureux is carbamazepine (Tegretol). Other anticonvulsants used include phenytoin (Dilantin) and gabapentin (Neurontin). These medications are generally started at a low dose and then increased until the pain is controlled or side effects occur. Common side effects include drowsiness, dizziness, double vision, and nausea. Rarely, serious liver or bone marrow problems can occur.
• Baclofen (Lioresal), a muscle relaxant, is useful for some people who either do not respond to anticonvulsants or who suffer serious side effects.
• Opioid pain medications can be useful during episodes of severe pain.
• Medication is effective for most patients. For some patients, drug therapy either fails to provide adequate pain control or adverse side effects are intolerable. Unfortunately, up to half of the people who initially respond to anticonvulsants eventually develop resistance to the medications.

When pain cannot be controlled with medication, surgical options should be discussed with a neurosurgeon. Surgery could range from simple injections of anesthetic into the trigeminal nerve to complex procedures that must be performed in the operating room. In general, the more complex procedures provide longer-lasting pain relief but with greater potential for more serious complications.

If you are diagnosed with tic douloureux, your doctor may refer you to a neurologist or neurosurgeon for the management of the pain.

• Some of the medications used to treat tic douloureux may affect your blood counts and liver function, so it is important to have these levels monitored by your doctor.
• After surgery, watch for signs of infection such as redness, discharge, or fever.

Tic douloureux cannot be prevented.

Although pain from tic douloureux can go away without treatment for months to years, the disorder is usually progressive. Attacks can become more frequent over time. There are no long-term medical consequences of the disorder. Tic douloureux is purely a pain syndrome.

• The pain of tic douloureux can almost always be controlled with either medication or surgery.
• Most people with tic douloureux lead full, complete lives.