Trigeminal Neuralgia and Hemifacial Spasm Treatment

The Department of Neurosurgery at Rutgers Health and RWJBarnabas Health offers advanced diagnostic, medical and surgical treatments for patients with trigeminal neuralgia, also called tic deouloureux. This rare, chronic nerve disorder causes excruciating pain, including sharp, burning, or shock-like sensations in the face. Trigeminal neuralgia cannot be cured, but treatment can effectively alleviate pain. Hemifacial spasms are often present with trigeminal neuralgia and are characterized by involuntary muscle spasms on one side of the face, usually without pain if it presents by itself.

Our neurology and neurosurgery department uses a multidisciplinary approach in treating neurological conditions like trigeminal neuralgia and hemifacial spasms. Under the medical care of our board-certified neurologists, neurosurgeons, and skilled support staff, you can achieve lasting pain relief for a better quality of life.

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What Is Trigeminal Neuralgia?

To better understand trigeminal neuralgia, it’s important to understand how the nerves are mapped out in your face. Your head has 12 pairs of cranial nerves, and the fifth pair of cranial nerves is called the trigeminal nerve, which has three branches running on both sides of the face. “Tria” means “three” in Latin, referring to the three branches of the trigeminal nerve, and “geminus” means twin, because the nerve runs through both sides of the face. The 3 branches provide sensation to the face, eyes, nose, lips, teeth, gums, tongue, and scalp. Trigeminal neuralgia usually only affects one side of the face, unless it is bilateral (affecting both sides).

The 3 branches of the trigeminal nerve include:

  • The ophthalmic branch: Controls the eye, upper eyelid, and forehead.
  • The maxillary branch: Affects the lower eyelid, cheek, nostril, upper lip and upper gums.
  • The mandibular branch: Provides sensation to the jaw, lower lip, and certain chewing muscles.

How Common Is Trigeminal Neuralgia?

According to the National Organization for Rare Disorders, up to 15,000 new cases of trigeminal neuralgia are diagnosed every year, nationwide. The Facial Pain Association states that about 4.3 per 100,000 individuals are newly diagnosed with trigeminal neuralgia every year in the United States.

A rare disease is defined as one which affects fewer than 200,000 people at any given time, making trigeminal neuralgia an extremely rare disease.

What Are Hemifacial Spasms?

Many trigeminal neuralgia patients also have hemifacial spasms, also called tic convulsif, a painless yet severe involuntary facial muscle twitch on one side of the face (“hemi-“ means “half”), which is treatable. This condition affects the seventh cranial nerve pair which primarily controls motor nerves of the eyebrows, eyes, and mouth and lips. Almost all cases involve spasms starting near the eyes and progressing down the face over time. Hemifacial spasms are often caused by injury to the facial nerves, a tumor or blood vessel pushing against the nerve, or Bell’s palsy (a paralysis of a portion of the face). Hemifacial spasms are very rare, affecting only 8 people per 100,000 nationwide.

Symptoms of Trigeminal Neuralgia

Whether you have typical or atypical trigeminal neuralgia, called Type 1 and Type 2, respectively, there is intense pain. Often, trigeminal neuralgia patients also suffer from chronic anxiety and depression. The symptoms are similar, but Type 1 usually presents with intermittent pain, while Type 2 pain is constant, although less severe.

Typical Trigeminal Neuralgia Symptoms include:

  • Intermittent stabbing, shooting, or burning pain that comes in bursts.
  • Sensations of electric shocks in the face when it is touched or otherwise triggered.
  • Pain can last for a few seconds or several minutes at a time, or for as long as two hours at a time.
  • Attacks occur several times per day or per week, followed by periods of remission.
  • Most patients only have pain on one side of the face, unless it is bilateral (affecting both sides of the face).
  • Attacks become more frequent and intense over time.
  • TM patients experience anxiety about when their next attack will occur.

Atypical Trigeminal Neuralgia Symptoms

Also called Type 2, this form of trigeminal neuralgia is far less common. Pain is the most common symptom, but it’s experienced at a much lower intensity than Type 1 trigeminal neuralgia. Pain may be constant, however, instead of coming in spurts.

Some of the triggers causing trigeminal neuralgia pain for Types 1 and 2 include:

  • Touching your face, even lightly
  • Making different facial expressions
  • Shaving your face
  • Putting on makeup
  • Brushing your teeth
  • Talking
  • Washing your face
  • A gust of wind
  • Eating or drinking
  • Blowing your nose

Causes of Trigeminal Neuralgia

Irritation, injury or trauma of the trigeminal nerve can trigger the pain associated with trigeminal neuralgia, but it is also associated with various conditions that put pressure on the trigeminal nerve in the area where it exits the brain stem. The compression may be the result of a blood vessel pressing on the nerve. Symptoms may present in patients with multiple sclerosis, brain tumors, or arteriovenous malformation. Injury may also cause neuropathic facial pain, which could result from sinus surgery, oral surgery, stroke, or direct trauma to the face.

It is most common in women who are over the age of 50, although it can occur at any age, including infancy.

Diagnosis of Trigeminal Neuralgia

Facial pain can be the result of a number of conditions, so it’s important for your doctor to do a thorough examination to determine the root cause. Although diagnosis is mostly determined by self-reported symptoms from the patient, there are specific tests a neurologist can perform. You doctor will ask you about the type of pain you’re experiencing and what triggers said pain. Your doctor will also ask what area of the face is affected, to determine whether the trigeminal nerve is involved.

Tests involved to diagnose trigeminal neuralgia include:

  • Imaging tests: a magnetic resonance imaging (MRI) scan of your head can determine if you have multiple sclerosis, or if a tumor is pushing against the trigeminal nerve. Some patients may have a dye injected into a blood vessel to better view the affected arteries, veins, and blood flow.
  • Neurological tests: A neurologist will touch and examine parts of the face to determine if the pain you are experiencing is related to trigeminal neuralgia. You may also be subjected to reflex tests to determine if you have compressed nerves, or another condition mimicking trigeminal neuralgia symptoms.

Trigeminal Neuralgia Treatment

A diagnosis of trigeminal neuralgia doesn’t mean you will be doomed to a life of pain and suffering. Our approach to treatment involves both nonsurgical and surgical treatments. Our board-certified neurologists, including those specializing in pain management, work together with neurosurgeons and expert support staff to help you achieve relief of facial pain and/or spasms.

Trigeminal neuralgia and hemifacial spasms can be effectively managed with the following treatments:

  • Medication: Patients may be prescribed anticonvulsant medications to slow down nerve conduction of pain signals, such as Tegretol, Neurontin, or Klonopin. Carbamazepine or oxycarzapine can be used to treat pain, and patients may have to try more than one medication for relief.
  • Injections: Peripheral nerve block injections can temporarily relieve pain. Some patients receive local injections of botulinum toxin (Botox) from a neurologist. Botox is injected into the affected facial muscles, which paralyzes or weakens them to decrease or completely eliminate spasms.
  • Balloon compression: A hollow needle is inserted into the face and guided to a part of the trigeminal nerve going through the base of the skull. A balloon is inflated with enough pressure to damage the trigeminal nerve, which can effectively block pain signals. Facial numbness is a potential side effect.
  • Radiosurgery: These surgeries use computer imaging to direct radiation where the trigeminal nerve exits the brain stem. CyberKnife® and Gamma Knife® surgeries are considered noninvasive and are performed on an outpatient basis. CyberKnife does not require incisions but requires a head frame attachment which produces radiation directed by laser to the nerve lesion to disrupt transmission of pain signals from the brain. Pain relief may take several months to take effect.
  • Gamma Knife, or brain stereotatic surgery, is similar, also requiring a head frame attachment to direct radiation to the trigeminal nerve to damage it and reduce pain symptoms.
  • Traditional surgery: Microvascular decompression (MVD) is the procedure recommended for patients who have not responded to other medical treatments, and who are otherwise in good health. Although it is an invasive procedure, it is proven to provide long-term relief for patients who are good candidates. During surgery, the patient is given general anesthesia, and a neurosurgeon identifies which blood vessel is pressing against the nerve. The blood vessel is then tacked away from the nerve with an insulating sponge, the bone that was removed from the face is replaced, and the skin is sutured.
  • Psychological support: Having trigeminal neuralgia can be very isolating and depressing for those who suffer from it. Seeing a psychotherapist or psychiatrist can be beneficial, and research has shown that lowering stress can effectively reduce chronic pain.
  • Complementary medicine: Some patients opt to try alternative medicine to cope with pain and anxiety. These may include acupuncture, hypnosis, nutritional therapy, vitamin injections, and more. These treatments must first be discussed with our neurology team to ensure they do not do more harm than good. Note, too, that these treatments are not proven to work or provide long-term relief, and they should only complement traditional medicine, not be standalone treatments.

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