Facial Pain and Trigeminal Neuralgia Care

If you have facial pain such as trigeminal neuralgia, turn to our world-renowned specialists at UC San Diego Health. We provide a leading-edge, multidisciplinary approach to facial pain.

Facial pain can come from a variety of sources, and diagnosing the cause is sometimes very complex. This means 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.

At UC San Diego Health we recommend starting with a neurologist. Our neurological care clinic can use a systematic approach to find the source of the pain. This begins with a detailed history and targeted physical exam, which may lead to specialized testing.

Common Causes of Facial Pain

Trigeminal neuralgia (TN) is a cranial nerve disorder that leads to facial pain. There are two types of TN: classic trigeminal neuralgia and secondary trigeminal neuralgia.

Classic Trigeminal Neuralgia (TN)

Also known as tic douloureux, classic TN often produces recurrent and abrupt pain like an electric shock. Classic trigeminal neuralgia is more frequent in older people, often with the first attack occurring in the late 50s or 60s. It’s rare before the age of 40. It’s usually caused by compression of a blood vessel at the root 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 and to rule out secondary tumors that appear like trigeminal neuralgia.

Secondary Trigeminal Neuralgia

Secondary trigeminal neuralgia occurs as the result of an underlying disease such as multiple sclerosis, a tumor, or an arteriovenous malformation (AVM).

Symptoms

This type of facial pain often shares many common characteristics with classic trigeminal neuralgia, including severe, sharp, electric pain that is worse with 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 patient’s 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.

Other 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 parts of the head and face. Sometimes facial pain is caused by a traumatic or surgical injury to the trigeminal nerve.

Surgeries for Facial Pain and Trigeminal Neuralgia

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 compressed vessel and who are fit for surgery.

The 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 cut 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 soft buffer.

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

Stereotactic Radiosurgery with Proton Beams

This procedure offers a less-invasive option for patients who are not candidates for microvascular decompression. Stereotactic 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. Our doctors meet to design the treatment, which involves focusing many proton 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, using fluoroscopic guidance, inserted where branches of the trigeminal nerve can be found.

Different 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)

Pain is alleviated by small, thin wire electrodes that can be placed underneath the skin in areas of the face where pain is felt. This procedure is first performed as a test for several days. If this improves at least 50% or more of the pain, we implant the electrodes 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.

Procedures for Facial Pain and Trigeminal Neuralgia

Procedures for facial pain range from injections — such as peripheral nerve blocks, occipital nerve blocks and sphenopalatine ganglion blocks — to Botox therapy. These procedures can be used as treatment options and occasionally as diagnostic tools to help understand the precise origin of pain.

Medications for Facial Pain and Trigeminal Neuralgia

Pharmacological Treatment

The type of medications we prescribe depends on the cause of facial pain. For classic trigeminal neuralgia, drugs such carbamazepine and oxcarbazepine are the preferred treatment.

Holistic Treatment

Some patients with facial pain benefit from holistic therapeutic options, such as massage or acupuncture. We strive to balance our treatments so that patients have access to different facets of medical care, including holistic treatment.