Brain; ENT; Eyes and Vision

What's causing ‘electric’ facial pain? It might be trigeminal nerve damage

Brain; ENT; Eyes and Vision

Young woman with facial pain caused by trigeminal nerve damage
Trigeminal neuropathy and neuralgia can cause shock-like, debilitating facial pain. But with a precise diagnosis, significant pain relief is possible.

Like a flash of lightning. An electric headache. Burning and stabbing. Patients describe trigeminal nerve pain in many different ways, but the common thread is that it’s almost always debilitating.

The trigeminal nerves run on both sides of the face, starting in the brainstem at the back of the head, branching like vines through the length of the skull. The nerves transmit touch and pain sensations to the brain from the eyes, eyelids, forehead, nostrils, cheek, lips, gums, jaws, and some muscles used for chewing.

When a trigeminal nerve is damaged, compressed, or irritated, it can shoot pain instantly through one side of the face. These intense episodes can last a few seconds or linger for hours, striking frequently or out of the blue after weeks or months of peace.

Trigeminal nerve pain can be caused by multiple factors, such as traumatic injury to the face or mouth, a stroke or tumor, or wisdom tooth extraction surgery – these are categorized as post-traumatic trigeminal neuropathic pain (PTTNp).

But in approximately 12 per 100,000 patients each year, there is no identifiable cause for the pain; this is called trigeminal neuralgia (TN).

Symptoms of facial pain and numbness are common in other serious conditions, and many patients endure multiple rounds of doctor visits and unnecessary procedures – like having all their teeth pulled – before getting a precise diagnosis from a facial pain specialist.

UT Southwestern’s oral and maxillofacial experts, neurologists, and neurosurgeons work together to identify the source of trigeminal nerve pain. Using advanced imaging technology, we can determine where and how severely your trigeminal nerve is damaged or compressed.

Most patients can manage pain with medication or outpatient nerve-repair surgery – I have performed more than 300 of these procedures for patients with PTTNp. Even if a specific nerve injury can’t be identified, we can recommend proven, effective treatment to relieve physical and mental health symptoms, improving your quality of life.

Trigeminal neuropathy: Facial pain after surgery or trauma

Trigeminal nerve damage can range from nerve irritation to a complete severing of the nerve. Injuries are classified as either recoverable (it can heal on its own) or non-recoverable (it cannot heal on its own). With non-recoverable injuries, a nerve is partially or completely severed and may form into a neuroma – a bundle of nerve tissue that seeks to attach to something, rewiring itself and sometimes causing excruciating pain.

Avneesh Chhabra, M.D.
Avneesh Chhabra, M.D.

Avneesh Chhabra, M.D., UT Southwestern’s Chief of Musculoskeletal Radiology, and I have developed criteria to determine whether a trigeminal nerve injury might be recoverable. We use magnetic resonance neurography (MRN), a high-resolution imaging technology that allows us to identify signs of healing without an invasive procedure.

Approximately 90% of PTTNp symptoms subside within eight weeks. While most recoverable injuries can be managed with pain medication, non-recoverable injuries often require microsurgery – as soon as possible – for the best chance at restoring sensation and relieving pain.

Having surgery within three months after the injury offers a 90-95% success rate for functional sensation recovery and up to a 70% chance of relieving pain. But after six months, the success rate is 60-70% and the chance of pain relief dwindles to 25%.

PTTNp microsurgery

Trigeminal nerve microsurgery is performed through the mouth, which means you will not have a visible scar. While you are under general anesthesia, the surgeon will open the tissue to expose the trigeminal nerve and, using imaging guidance, find the damaged area. Then the surgeon will perform one of these corrections:

  • Repair a tear in the nerve
  • Reconnect the ends of a severed nerve
  • Place a nerve allograft (from a cadaver) to bridge the gap between injured nerve endings

Trigeminal nerve microsurgeries take about 90 minutes, and most patients can leave the hospital the day of the procedure. Within 3-5 days, most patients can resume their normal activities. We will see you for follow up every three months to measure your progress during the first year post-surgery. Sensation and pain relief should improve over time, depending on the severity of your injury and timing of the procedure.

Trigeminal neuralgia: Facial pain without a known cause

Trigeminal neuralgia, also called tic douloureux, is the most common type of facial neuropathy. TN often affects people older than 50 and is more common in women. People with trigeminal neuralgia are more likely to have psychiatric conditions such as anxiety and depression. Concern about triggering pain may result in self-isolation and decreased quality of life.

Diagram of the trigeminal nerve
The trigeminal nerves run on both sides of the face, starting in the brainstem at the back of the head, branching like vines through the length of the skull. The nerves transmit touch and pain sensations to the brain from the eyes, eyelids, forehead, nostrils, cheek, lips, gums, jaws, and some muscles used for chewing.

Though the exact source of TN often can’t be found, approximately 75-80% of cases are associated with pressure or irritation on the nerve from the superior cerebellar artery, which feeds blood to the part of the brain behind the brainstem.

The classic shock-like pain can strike without warning or be triggered by lightly touching the face or teeth during daily activities, such as:

  • Applying makeup
  • Brushing your teeth
  • Eating or drinking
  • Exposure to wind
  • Shaving

While imaging can help us rule out what is not causing your pain – such as a tumor, sinus disease, temporomandibular joint (TMJ) disorders, or tooth problems – there is no specific test to diagnose TN.

Precise diagnosis is highly personalized and starts with a facial pain specialist who listens to how you describe your symptoms. By combining our expertise in neurology and maxillofacial nerve care, our multidisciplinary facial pain team can personalize a treatment plan to improve your quality of life.

TN treatment options

Approximately 80-90% of patients can achieve full or partial TN pain relief with medications commonly prescribed for controlling seizures, such as carbamazepine, which are thought to stop pain signal transmission to the brain. IV-delivered lidocaine and magnesium to control pain or BOTOX® injections to numb the nerves also may be effective.

While TN can resolve over time, medication doesn’t work for some patients. In those cases, we refer you to one of our neurosurgeons to evaluate whether a procedure can relieve or cure your TN pain.

Neurosurgery or radiosurgery procedures such as these have proven effective in reducing or resolving TN pain:

  • Microvascular decompression: While the patient is under general anesthesia, the neurosurgeon drills a small hole in the skull behind the ear. Using microscopic guidance, they place a tiny pad between the trigeminal nerve and the blood vessel pressing against it. Patients stay in the hospital 2-3 days and can resume normal activities within 4-6 weeks. Long term, the success rate is approximately 80%.
Using Gamma Knife radiosurgery, our specialists can target the trigeminal nerve with a precise dose of radiation so it can no longer transmit pain signals.
  • GammaKnife® radiosurgery: This outpatient procedure requires no incisions and only light sedation. From outside the skull, a neurosurgeon applies controlled beams of radiation to damage the trigeminal nerve so it can no longer transmit pain signals. Most patients can resume normal activities within 48 hours. Within a year, approximately 80% of patients will have significantly less TN pain.
  • Radiofrequency ablation: For this outpatient procedure, a neurosurgeon applies controlled heat to the trigeminal nerve through an electrode placed in the cheek, disrupting pain signal transmission. Approximately 90% of patients get immediate relief, though some will experience more facial numbness. Pain returns in 40% of patients after two to three years, and this procedure can be repeated as needed.

While trigeminal nerve pain is not directly life-threatening, it can negatively affect your quality of life to the point of disability. With a personalized approach, we can help you return to everyday activities with less facial pain.

To visit with a trigeminal nerve disorders expert, call 214-645-8300 or request an appointment online.

Meet Dr. Zuniga

As an experienced trigeminal nerve microsurgeon, John Zuniga, D.M.D., Ph.D., has performed more than 300 nerve repairs. He also has a clinical interest in trauma of the oral and maxillofacial region. His research interests include chronic and acute orofacial pain and trigeminal neurosensory disorders.

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