Facial Pain Care

At UC San Diego Health, our world-renowned specialists offer a multidisciplinary approach to facial pain.

Facial pain can come from a variety of sources, and diagnosing the cause is sometimes very complex. Therefore, patients often see many types of doctors, including dentists, ear, nose and throat (ENT) specialists, pain specialists, neurosurgeons and neurologists. This can be confusing and time-consuming.

To determine the right treatment, we use a systematic approach to find the source of the pain, beginning with a detailed history and targeted physical examination, which may lead to specialized testing.

Common Causes of Facial Pain

The trigeminal nerve, or Cranial Nerve Number 5, is the nerve that controls light touch, as well as the transmission of pain and temperature to various regions of the head and face.

Trigeminal neuralgia (TN) is a syndrome that leads to facial pain, with between 4.5 and 28.9 new cases per 100,000 people each year. Because it is often confused with other types of facial pain syndromes, TN is overdiagnosed and, therefore, sometimes mistreated. There are two types of TN:

Classic Trigeminal Neuralgia (TN)

Also known as tic douloureux, classic TN often produces recurrent and abrupt "electric shock-like" pain. TN affects one or more branches of the trigeminal nerve, most commonly in the second or third division. Classic trigeminal neuralgia is more frequent in older populations, often with the first attack occurring in the late 50s or 60s — it is rare before the age of 40. It is usually caused by compression of a blood vessel at the root entry zone of the trigeminal nerve in the brain.

Symptoms:

Pain may last for a few seconds or, in some cases, persist for up to two minutes and usually occurs only on one side of the face.
The duration of pain attacks can change over time and become more prolonged and severe. Between those pain attacks, most patients do not report any pain.
Typical trigeminal neuralgia pain is often triggered by a light touch of the face (such as by applying makeup or shaving), brushing teeth, and chewing, among other things.

Diagnosis:

Patients complete a questionnaire, and a specialist takes a detailed history and conducts a physical exam.
Our radiologists perform a specialized set of imaging sequences to confirm the diagnosis of trigeminal neuralgia and, more importantly, to rule out secondary trigeminal neuralgia-like tumors.

Secondary Trigeminal Neuralgia

While classic trigeminal neuralgia can occur in patients below age 50, other diagnoses causing facial pain, specifically multiple sclerosis, can be considered in younger patients.

Symptoms:

This type of facial pain often shares many common characteristics with classic trigeminal neuralgia, including severe, sharp, electric pain that is worsened by a light touch of the face.
Patients who also complain of sensory symptoms, like numbness and tingling, are more likely to have secondary trigeminal neuralgia.

Diagnosis:

Depending on the history and examination, tests may include a different type of specialized brain MRI, a CT scan of the face and sinuses, and a special set of blood tests.

Treatment Options for Facial Pain We offer several therapeutic and surgical options for facial pain based on individual patient needs.

Pharmacological Treatment

Holistic Treatment

Procedural Treatment

Surgical Treatment

Neurosurgical management of facial pain is complex, and our technique depends on the source of the pain. Options include:

Microvascular decompression (MVD) of the trigeminal nerve

This is the treatment of choice for patients with classic symptoms of trigeminal neuralgia whose MRI reveals a compressive vessel and who are fit to undergo surgery.

This procedure involves making a small, linear incision behind the ear and a quarter-sized opening in the skull to access the region of compression with a microscope. The offending vessel is dissected away from the nerve and moved aside. The vessel and the nerve are traditionally kept away from each other long-term by placing a piece of Teflon, a substance that acts as a pillowy buffer.

At UC San Diego Health, we have pioneered a novel approach to displacing the vessel, which we use in certain circumstances. This procedure involves creating a sling in which the artery is tacked up away from the nerve without the need for foreign material.

Gamma Knife Radiosurgery

This procedure offers a less-invasive option for patients who are not candidates for microvascular decompression. Gamma knife radiosurgery is not surgery and does not involve a skin incision or anesthesia. In this procedure, a special head frame is placed, and an MRI is used to precisely locate the nerve.

The physicians hold a planning session to design the treatment, which involves focusing many beams of radiation through the skin and precisely targeting the trigeminal nerve. The procedure does not cause pain. The treatment takes several weeks to several months to take full effect.

Percutaneous Procedures

In some cases, your neurosurgeon may offer percutaneous procedures, in which a needle is placed through the cheek and, under fluoroscopic guidance, inserted into the foramen ovale, where branches of the trigeminal nerve can be found. Different therapeutic options using this technique are possible, including injecting a numbing medication called Glycerol, radiofrequency ablation (RF ablation), or balloon compression of the nerve.

Peripheral Nerve and Peripheral Nerve Field Stimulation (PNS and PNFS)

Small, thin wire electrodes can be placed underneath the skin in areas of the face where pain is felt, thereby alleviating the pain. This procedure is first performed as a trial, where its efficacy is tested for several days. If the stimulation relieves at least 50% or more of the pain, the electrodes are implanted as a permanent stimulator.

Nucleus Caudalis Dorsal Root Entry Zone Lesioning (DREZ)

In certain circumstances, a different part of the pain pathway must be targeted to relieve pain. In this procedure, a specialized probe is used to target the nucleus caudalis, a nucleus in the brainstem that controls pain processing in the facial region.