Trigeminal Neuralgia

Symptoms, triggers and warning signs

The classic attack is a stab or an electric shock on one side of the face that lasts only a moment. It usually hits the cheek or jaw, far less often the forehead. The attacks are set off by light touch or movement: washing the face, brushing the teeth, chewing, talking or a cold breeze.

Some signs point to a different cause and need an early scan: pain on both sides of the face, numbness or weakness in the face, hearing loss or ringing in one ear, and onset in a young adult. Rarely, a brain tumour or multiple sclerosis presses on the nerve and produces the same pain, so an MRI is part of the work-up.

Why it is often mistaken for a dental problem

Because the pain sits in the jaw and the teeth, most patients go to a dentist first. The tooth looks normal on X-ray, but the pain is so convincing that a root canal or an extraction is tried, then another, with no relief. Some patients lose several teeth before anyone considers the nerve. Dental pain is usually a constant throb, worse on biting a particular tooth, and eases with painkillers. Trigeminal neuralgia is a shock that comes and goes in an instant, set off by a light touch on the skin rather than by biting. If a tooth has been treated and the shocks continue, think of the nerve before any more dental work.

Causes and who gets it

In most patients the cause is a small artery or vein lying against the trigeminal nerve close to where it enters the brainstem. Over years the pulsing vessel wears away the nerve's insulating coat, and the bare fibres short-circuit, which the brain reads as pain. This is why it usually begins in middle age or later and is rare in children. A few patients have multiple sclerosis, which damages the same coating, or a tumour pressing on the nerve. Sometimes no cause is found even on a good MRI, and treatment rests on the symptoms alone.

How it is diagnosed

There is no blood test for trigeminal neuralgia. The diagnosis rests on the story: where the pain is, how long each attack lasts, what sets it off and how it responds to medicine. Dr. Salman Falak listens carefully, then examines the face for any loss of feeling or weakness and checks the other nerves of the head. An MRI of the brain is arranged to look for a vessel lying against the nerve and to rule out a tumour or multiple sclerosis. A good response to the first nerve-calming medicine also supports the diagnosis.

Treatment: medicine first, then surgery

The first treatment is almost always a tablet. Anti-seizure medicines such as carbamazepine calm the over-active nerve and bring the attacks under control in many patients, often within days. They can cause drowsiness and unsteadiness, especially in older people, and need occasional blood tests, so Dr. Salman Falak monitors them closely.

Surgery is considered when the medicine stops controlling the attacks, or the dose needed causes side effects the patient cannot live with. The main operations are microvascular decompression, in which the surgeon lifts the blood vessel off the nerve and places a small cushion between them, and needle procedures through the cheek that deliberately damage part of the nerve to stop it firing. Each has its own benefits and risks; the choice depends on the patient's health and what the MRI shows. The operations Dr. Salman Falak performs are described on the trigeminal neuralgia surgery page.

What recovery looks like

On medicine, most patients notice the attacks become fewer and weaker within days, and many have long stretches with no pain. The condition can flare again over the years and the dose may need adjusting. After microvascular decompression, the shocks often stop straight away, and patients spend a few days in hospital before going home. After a needle procedure the stay is shorter, but part of the face may feel numb and the pain can return later in some patients. Follow-up for patients from other cities is usually by video.

When to see a neurosurgeon

See a neurosurgeon if you have short electric-shock pains on one side of the face set off by touch or chewing, especially if dental treatment has not helped. Come too if you are on medicine and the attacks are breaking through, or the tablets make you too drowsy. Pain with numbness or weakness of the face should be scanned without delay. Patients from Gujranwala or Faisalabad can start with an online consultation and send any MRI they have on WhatsApp. Trigeminal neuralgia surgery is one of the operations listed under brain surgery.