What Is Trigeminal Neuralgia? Causes and Treatments Explained

If you’ve experienced trigeminal neuralgia (TN) you’ll certainly know about it. Described by the Trigeminal Neuralgia Association UK as ‘the worst pain known to man’ (i), it causes sudden, severe facial pain.

Thankfully, however, TN is rare. Estimates vary as to how many people are affected, with some figures suggesting between 10 and 20 people in 100,000 develop TN in the UK every year (ii). Most of those affected are older, with symptoms usually starting in people in their 50s, 60s and 70s (ii). TN is also thought to affect more than twice as many women as men (iii), but it’s rare in people under 40.

With attacks described as feeling like an electric shock, living with TN can be difficult. During a flare-up you may have pain for just a few seconds, or you may experience quick bursts of pain one after another for several minutes. Some people have pain a few times a month, while others may have several or more pain attacks a day. Indeed, according to the National institute of Health and Care Excellence (NICE) some people with TN experience pain hundreds of times a day (iv).

For most people with TN the condition is progressive, which means it becomes worse and more frequent the longer they have it. It isn’t, however, a life-threatening condition. But because the pain can be so debilitating it tends to have a significant impact on quality of life, leading to complications such as:

• Depression

• Anxiety (caused by the thought of the pain returning)

• Isolation

• Weight loss (you may find it difficult to eat)

• Inability to carry out daily activities

• Dental problems (it may hurt to brush your teeth)

While there is no cure, the good news is that there are treatments that can help you control TN pain and things you can do yourself to reduce it. 
 

What are the symptoms?

A TN attack often starts with a feeling of tingling or numbness in the face, followed by sharp, stabbing pain that can be very intense and severe.

Most people experience it on one side of their face (unilateral), usually in the cheek or lower jaw and more commonly on the right side of the face than the left. Experts from NICE suggest only three per cent of cases are bilateral, which means experiencing pain on both sides of the face (v) – though it’s rare for anyone to have acute pain on both sides at the same time (i).

Sometimes, TN pain can be felt inside the mouth, and some people have said it feels as if the pain is coming from one or more of their teeth. This explains why many with TN see their dentist when they first experience the symptoms, and according to the Trigeminal Neuralgia Association UK some have unnecessary dental treatment before they get a correct diagnosis (i).

As well as in the cheek and lower jaw, pain can be felt in the lips, eyes, nose, scalp, forehead and upper jaw. All of these symptoms are typical of the classic form of the disorder, which is sometimes called TN1.

There is also an atypical form of TN, called TN2. Unlike the pain of classic TN this causes a relentless underlying pain – similar to that of a migraine – sometimes with an intense burning sensation, along with stabbing pains that are less intense than with TN1. Treating atypical TN is particularly difficult. However, the majority of TN cases are thought to be the classic type.
 

Pain-free periods

After a flare-up – which can last up to a few weeks or a few months – you may not get any more symptoms for a while, perhaps not even for a few years. According to NICE, remission rates for TN are as follows (vi):

• 50 per cent of people with TN experience pain-free periods of at least six months at a time.

• 65 per cent of people who have just been diagnosed with TN have a second episode within five years.

• 77 per cent of people newly diagnosed with TN have a second episode within 10 years.

• Those with atypical TN (TN2) tend to experience lower-intensity background pain for 50 per cent of the time.

However, periods of remission tend to get shorter as time goes by, and as with other progressive conditions, flare-ups also tend to last longer.

What causes trigeminal neuralgia?

In around 95 per cent of cases, TN is thought to be caused by compression of the trigeminal nerve (vii).

The trigeminal nerve is one of 12 pairs of cranial nerves that connect your brain to various parts of your head, neck and trunk. It has three main branches on either side of the face, called V1, V2 and V3:

• V1 is the opthalmic branch of the trigeminal nerve, and runs through the eye, forehead and nose.

• V2 is the maxillary branch, running through the upper teeth, gums, lip, cheek, lower eyelid and the side of the nose.

• V3 is the mandibular branch, running through the lower teeth, gums and lip. 

The nerve can become injured when, for instance, a blood vessel presses against it. Over time this pressure can damage the protective sheath that insulates the fibres of the nerve, called the myelin sheath. When this happens, the nerve can become exposed and very sensitive, which makes the nerve fibres send pain signals to the brain for the slightest reason.

According to the NHS, however, it’s still not clear why this may cause TN symptoms in some people but not others, since not everyone with a compressed trigeminal nerve experiences pain (viii). It also doesn’t explain why many people with TN have periods without symptoms – though according to the Trigeminal Neuralgia Association UK, it’s thought that the myelin sheath tries to heal itself, which may sometimes cause periods of remission (i).

TN can also be caused by another medical condition or problem, such as multiple sclerosis, a tumour or cyst, facial injury, damage caused by surgery (dental surgery, for example) or arteriovenous malformation, which is an abnormal tangle of blood vessels connecting the arteries and veins. Some experts are also looking into a condition called postherpetic neuralgia – that is, the pain caused by shingles – and whether or not it may be related to TN (ix).

TN triggers

With classic TN there are many things that can trigger an attack – though attacks can also happen for no obvious reason. These triggers include:

• Brushing your teeth

• Washing your face

• Shaving

• Applying make-up

• Talking

• Smiling

• Eating

• Swallowing

• Yawning

• Moving your head

• Vibration (eg walking, travelling by car etc.)

• Kissing

• Touching your face, even very lightly

• Exposure to cold (including air conditioning) or even just a cool breeze

 

How is trigeminal neuralgia treated?

There aren’t usually any tests for TN, as diagnosis is often based on the symptoms –  though some people may need an MRI scan if their symptoms aren’t typical. Once diagnosed, you may be offered treatments to help relieve the pain.

Knowing what triggers your symptoms can also be useful, since some – though not all – can be avoided. You may also be able to find solutions to stop some triggers causing an attack. For instance, if you know that contact with cold air causes pain, try wearing a scarf wrapped around your face in cold or windy weather, or avoid sitting near open windows or air conditioning vents.

According to the NHS, most people with TN are treated with prescription medicines (x), since over-the-counter painkillers such as paracetamol and even prescription painkillers such as codeine aren’t effective.

Carbamazepine

This is the main treatment for TN, despite the fact that it’s an anticonvulsant medicine that’s normally used to treat epilepsy. In TN it’s thought to work by reducing nerve impulses and restricting their ability to send pain signals to the brain. Indeed, experts think that carbamazepine could ease pain in most people living with TN within one or two days (xi).

Carbamazepine is usually taken regularly while you’re having a flare-up, but it can be stopped if you’re in remission, then started again when you get another flare-up. However follow your GP’s instructions carefully, especially regarding increasing and decreasing your dosage over a period of a few weeks or so. This is because it can be harmful to take too much too soon or to stop taking carbamazepine too quickly. 

Carbamazepine, however, can cause side effects in some people. Speak to your GP if you’re experiencing anything unusual while taking it, such as dizziness, confusion, nausea or tiredness.

Other drug treatments   

If carbamazepine doesn’t work well for you or if it causes troublesome side effects, there are other medicines you could try – though these aren’t specifically licensed to treat TN. These include medicines such as gabapentin and oxcarbazepine, which are thought to work by dampening nerve impulses.

Surgery   

Some people may be offered surgery to treat TN symptoms if medication doesn’t work for them or if they experience side effects from their medicines that they find difficult to cope with. According to the NHS there’s no guarantee surgery will work, but if it does you won’t have to take any more medication (unless, of course, your flare-ups return) (x).

There are different types of surgery available, including:

Microvascular decompression

This operation aims to relieve the pressure on the trigeminal nerve and is the most successful procedure for providing long-lasting relief from TN pain. On the other hand it’s a major operation that involves opening the skull under general anaesthetic. It also has a small risk of complications that could be serious, including hearing loss, stroke and facial numbness.

Ablative surgery

This means surgery that destroys or injures tissue in the body – in the case of TN, the tissue that’s damaged or destroyed is the trigeminal nerve, including the nerve root.

There are a few different types of ablative procedures used to treat TN, including gamma knife surgery (or stereotactic radiosurgery) and percutaneous procedures, where a needle or thin tube is inserted through the cheek and into the trigeminal nerve itself.

Some of these can be performed under local anaesthetic (stereotactic radiosurgery, for instance), while for others you’ll need a general anaesthetic. And while they may not be as successful as decompression surgery, they have a much lower risk of complications.

How to help yourself

The good news is that, while there may not be any cure for TN, researchers in the UK and elsewhere in the world are constantly investigating new treatments and medicines. In the meantime, there are a few things you could do yourself that may provide some relief:

Diet considerations

If you have TN it may be worth trying to cut down on the amount of saturated fat you eat. Researchers writing in the journal Neurology (xii) looked into this approach, and found that 71 per cent of those who had classic TN experienced less pain within just a month of restricting the amount of saturated fat they ate. However, it’s worth bearing in mind that this trial was a small one, including just 55 people with TN.

A published case study also found that TN may be triggered by sour and spicy foods (xiii). Researchers writing in the Journal of Oral & Facial Pain and Headache followed an 81-year-old woman who had been having TN attacks since she was 50. The case study found that sour and spicy foods triggered her symptoms, so she avoided them. After looking into the possible mechanisms behind this, the researchers suggested that sour and spicy foods may activate trigeminal receptors.

Other foods you may want to consider avoiding include caffeine, citrus fruit and bananas, says the NHS (x) – or indeed any foods that trigger your symptoms.

However, it’s important to keep your nutrient levels up, so try not to skip meals. And if the action of eating or chewing triggers your symptoms, try liquidising your food to make things easier. Eating as many soft foods as possible may also be useful. According to the Facial Pain Association in the US (xiv), some ‘safe’ foods include:

• Brown rice

• Cooked or dried fruits such as cherries, cranberries, pears and prunes

• Cooked vegetables such as artichokes, asparagus, broccoli, lettuce, spinach, beans, squash and sweet potatoes

You could also try using a straw to drink warm or cold drinks if you have any painful areas in your mouth.

Meanwhile, staying physically active may be another good idea, since exercise is known to help with stress and low mood, and may help distract you from any anxiety you may be experiencing. But if you find that exposure to cold air triggers your pain, stick to indoor activities. And remember to speak to your GP before starting any new exercise routine, especially if you haven’t been very active lately.

Finally, it may also be a good idea to supplement your diet with a good multivitamin and mineral with decent levels of vitamin B12, as it may help support your overall health, especially if your diet isn’t as varied or balanced as it should be.

You may also want to consider trying a supplement called PEA, which is short for palmitoylethanolamide. PEA is a type of fatty acid that’s often recommended by natural practitioners for nerve pain and neuralgia. Made naturally by the body and found in all cells, tissues and fluids including the brain, PEA is also found in foods such as soya beans, peanuts, eggs, flaxseed and milk. Described as an endocannbinoid-like chemical that belongs to a family of fatty acid compounds called amides (xv), it’s an alternative to CBD, since both substances are thought to have similar properties including the ability to reduce pain and inflammation. However researchers suggest PEA is safer than CBD, since it has been studied more extensively and has a more robust safety profile (xvi) with no known side effects (xvi).

Your body naturally increases its production of PEA when your cells are damaged or threatened. But in certain situations – such as when your body is experiencing chronic inflammation – the level of PEA in your cells drops (xv). When this happens, PEA supplements may be helpful. In fact there are studies that suggest PEA may help relieve neuropathic pain significantly (xvii).


Living with a condition that causes severe, long-term pain such as trigeminal neuralgia can be extremely stressful. This guide aims to give you the information you may need to tackle it and carry on with your daily life. For more information on medical conditions that cause pain, visit our health library. 

References:

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 
 

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