Trigeminal neuralgia is a condition involving an irritation of the trigeminal nerve causing severe facial pain, and may induce involuntary facial muscle spasm or a ‘tic’ (hence trigeminal neuralgia is also known as ‘tic douloureux’). It is not the only cause of severe facial pain, and in fact not even the most common (affecting 0.01% of the population), behind headaches that refer to the face (3%), and temporomandibular (jaw) disorders (5-12%). (1-3)
Who should you see and what treatment should you get? How do you know if the pain you are experiencing is as a result of a ‘headache’ in the face caused by an irritation of the brainstem (or the trigemino-cervical complex), a jaw problem or a direct irritation of the trigeminal nerve (trigeminal neuralgia)?
The pain behaviour of trigeminal neuralgia is quite distinct, and using a highly skilled manual therapy method known as the Watson Headache ® Approach, we can (in the case of headache associated face pain) directly test for the source of your pain.
The trigeminal nerve is the primary sensory nerve for the head and face relaying sensations of touch, pain, temperature, muscle contraction, and stretch. In other words the trigeminal nerve is responsible for everything you feel from the head and face (including the external ear up to and including the tympanic membrane or ear drum), excluding the special senses - sight, hearing, taste, and smell. The trigeminal nerve also sends back information from a wide variety of blood vessels including the inner ear and vestibular apparatus, as well as the meninges that lines the brain.
It also has control of a small group of muscles including the muscles of mastication (chewing) and the small muscle that surround the ear drum (tensor tympani). It is the fifth (or ‘V’) of twelve cranial nerves and has three (hence ‘tri’) branches. The top branch runs through the temple to the back of the eye and covers the scalp ⅔ of the way to the back of the head, and is known as the opthalmic branch or V1. It also penetrates the sutures or joins between the skull bones to reach the blood vessels under the skull on top of the meninges - the ‘skin’ that covers the brain and spinal cord. The second branch runs through the upper jaw bone or maxilla, and is the maxillary branch or V2, with the third branch being the mandibular branch or V3. Trigeminal neuralgia most commonly affects mandibular (V3) and maxillary (V2) branches of the trigeminal nerve. If the opthalmic branch (V1) is involved it is almost always with the maxillary branch as well.
Like the branches on a tree, the individual nerves converge into a main trunk just behind the ear and enter the base of the skull, travelling into the brainstem (marked in pink on the picture above) where they mix with the upper three cervical (neck) nerves - a place called the trigemino-cervical complex. Essentially, trigeminal neuralgia is an irritation of the trigeminal nerve after it leaves the skull, and headache in all its forms is an irritation of the trigeminal nerve in the brainstem. Successful treatment relies on identifying where the nerve is irritated. If the irritation occurs in the trigemino-cervical complex we can directly test it using the Watson Headache ® Approach. If the irritation occurs after the trigeminal nerve has exited the skull the pain behaviour is markedly different and so is the treatment, usually involving medications and possibly surgery.
The best way to know what is causing your facial pain is to book an assessment with someone trained to understand the differences. We are looking for particular characteristics about the pain, how it behaves, where it is located (and where it isn’t!). We can also directly test the brainstem (trigemino-cervical complex) and see if it causing the problem. If pressure on the segments in the top of the neck reproduces your familiar facial pain we can help you.
What are the symptoms of trigeminal neuralgia?
Typical or classic Trigeminal neuralgia is characterised by:
Brief episodes (seconds to minutes) of stabbing, shooting, sharp or ‘electricity-like’ pain located in the face - commonly the cheek, lips or jaw, but may involve the side of the nose, inside of the mouth, eye or and much less commonly forehead.
Pain is usually confined to one side of the face, but very rarely can be on both sides, with episodes coming in waves or cycles, with lasting days to weeks before easing for similar periods, then returning.
Pain is triggered by light facial touch, such as talking, eating, brushing teeth, wind etc
Most commonly occurs in people’s 40’s, 50’s and 60’s.
Pain usually responds to medications - carbamazepine (tegretol) or oxcarbazepine (trileptil)
Whilst these are the classic symptoms of ‘typical Trigeminal Neuralgia’, there are two headache disorders known as SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing) and SUNA (Short-lasting Unilateral Neuralgiform headache attacks with Autonomic symptoms) which can present in almost identical ways and needs to be excluded. If the pain is focussed around the eye and associated with eye redness (conjuctival injection), tearing/watery eye (lacrimation) and/or swelling/closing of the eyelid (ptosis) you may well have SUNCT or SUNA and not trigeminal neuralgia.
What are the symptoms of headache with facial pain?
If your facial pain is characterised by:
Onset under the age of 30
Pain lasting hours to days, with regular frequency - i.e. one to two episodes per week/month
Pain that is aching, squeezing, throbbing
Pain is not typically ‘provoked’ or ‘triggered’ by light touch, chewing, brushing teeth, wind
Pain predominantly involves the forehead, eyes, top of the head, above the ear or temples as well as in the middle and/or lower parts of the face.
Pain on both sides or alternating from one side to the other
Pain responds to regular painkillers such as paracetamol, panadeine, aspirin or ibuprofen, and or has responded (even in the short term) to massage of the head or neck.
Presence of nausea, sensitivity to light or sound, or tightness/pain in the neck, tearing, redness of the eye or runny nose.
Whilst these symptoms may describe ‘atypical’ trigeminal neuralgia, far more commonly this presentation is the product of an overstimulated trigemino-cervical complex and is the type of facial pain we most commonly treat. A key part of diagnosing our ability to treat is whether we can demonstrate temporary reproduction of typical symptoms with stimulation of the trigemino-cervical complex with direct pressure on key points in the top of the neck.
If your presentation is ‘atypical trigeminal neuralgia’, it is important to rule out the neck as the source of symptoms before undertaking invasive surgical procedures. The Watson Headache ® Approach used exclusively at The Melbourne Headache Centre, is able to directly test whether the pain in your face is coming from a sensitivity created by the neck. During the assessment we are looking for three key factors:
Do you have a small fault which creates spasm in OCI?
Can we treat the fault and correct the muscle spasm within approximately 30 seconds of treatment to the right parts of the neck?
Properly identifying and treating the cause for this muscle spasm is a critical step that is often missed, and has a profound effect on the response to treatment. The ability to provide the Watson Headache ® Approach at a highly skilled level sets the The Melbourne Headache Centre apart for treatment of this disorder. With standard therapy to the neck this muscle is either ignored, stretched for short term relief, or aggravated with over-zealous treatment. 3. Is it relevant to your condition? In the case of atypical trigeminal neuralgia we can stress the top of the neck to demonstrate a reproduction and easing of familiar symptoms. That means, can we push on your neck and you not only feel pressure on your neck, but also pain referring into the areas of the face affected by your condition, then, as we sustain the pressure, we see the referred symptoms ease. This reproduction and resolution of familiar symptoms is a key indicator that the Watson Headache ® Approach will be beneficial.
Many traditional approaches to neck treatment merely stretch or massage this muscle inducing a temporary relaxation, usually resulting in short lived relief of symptoms. At times the ‘restore the normal movement’ philosophy is too heavy handed, adding to the already overloaded neck inputs, and symptoms can be aggravated.
We understand this, and deal with sensitive and chronic cases all the time. We need to decrease the input from the upper neck, not ‘beat it into submission’ and we need to make changes that will last more than a few days. Treating OCI is not usually about ‘deep and painful’ manual stretching techniques. It is about identifying the small fault that is causing it to go into a protective spam in the first place. Using the Watson Headache ® Approach, this is exactly what we are trained to do.
Trigeminal Neuralgia Diagnosis
The International Classification of Headache Disorders (ICHD-3) has trigeminal neuralgia described under part 3: ‘Neuropathies and Facial Pains and other headaches’. The diagnostic criteria is:
Recurrent paroxysms of unilateral facial pain in the distribution (s) of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C.
A. Pain has all of the following characteristics:
Lasting from a fraction of a second to 2 minutes
Electric shock like, shooting, stabbing or sharp in quality
B. Precipitated by innocuous stimuli within the affected trigeminal distribution C. Not better accounted for by another ICHD-3 diagnosis.
Trigeminal Neuralgia Australia has a broader description of the different forms of TN and describes a number of different forms of Trigeminal neuralgia:
Trigeminal Neuralgia type 1 (TN1): classical form where episodic lancinating pain predominates, also known as “typical trigeminal neuralgia”
Trigeminal neuralgia type 2 (TN2): atypical form where pain is aching, throbbing or burning and constant for >50% of the time, also known as “atypical trigeminal neuralgia”
Trigeminal neuropathic pain (TNP): pain related to unintentional injury to the nerve from facial trauma, ENT surgery, oral surgery, posterior fossa surgery or stroke.
Trigeminal deafferentation pain (TDP): pain related to intentional injury to the nerve such as rhizotomy, neurectomy, gangliolysis or other denervating procedure.
Symptomatic trigeminal neuralgia (STN): pain associated with multiple sclerosis.
Postherpetic neuralgia (PHN): pain following an outbreak of facial herpes zoster.
Atypical facial pain (AFP): pain predominantly having a psychological rather than physiological origin.
Diagnosis relies on exclusion of pathologic causes such as multiple sclerosis or a brain tumour, (often done with an MRI), and a detailed history of how the pain behaves.