Home / Conditions / Trigeminal neuralgia
Sudden, severe, electric-shock pain in one side of the face, set off by something as light as a breeze or a toothbrush. It is one of the most severe pains in medicine — and one of the most treatable.
The trigeminal nerve carries sensation from your face to your brain. In trigeminal neuralgia it misfires, producing sudden bursts of intense pain — usually described as electric shocks, stabbing or lightning — in one side of the face. It is the most distinctive of the facial pain conditions, and among the most treatable.
Each attack lasts seconds to a couple of minutes. They come in volleys, sometimes dozens in a day, then stop for weeks or months before returning. Between attacks there is usually no pain at all, which is part of what makes the condition so distinctive.
It is also called tic douloureux, from the involuntary wince an attack provokes.
The trigger is almost always ordinary and light — not pressure, not injury. That mismatch between trigger and pain is characteristic.
People often develop habits around this without realising: chewing on one side only, avoiding cold drinks, leaving one part of the face unwashed or unshaven, speaking less. Those adaptations are frequently the first thing a partner notices.
Because the pain sits in the jaw, teeth or gums, the first stop is usually a dentist — and this is where real harm happens. People have teeth drilled, root-treated or extracted for pain that was never coming from the tooth.
Two things distinguish it from dental pain:
If dental treatment has not helped, or the pain continued after a tooth was removed, that is a reason to have the nerve assessed rather than to treat the next tooth along.
In most cases a blood vessel lies against the trigeminal nerve where it leaves the brainstem. Over years, the pulsation wears away the nerve's insulating sheath. The exposed nerve then fires spontaneously, and signals intended for light touch get read as pain.
Less commonly it results from a tumour pressing on the nerve, or from a condition affecting the nerve's insulation directly. That is why imaging forms part of the assessment rather than being optional.
Trigeminal neuralgia in someone under 40, or affecting both sides of the face, is less typical and prompts a wider look for an underlying cause.
The diagnosis is clinical — made from the character of the pain, its distribution over one or more branches of the nerve, and the triggers. There is no test that confirms it.
A striking response to the first-line medication is itself supportive of the diagnosis, and is often how it is confirmed in practice.
Almost everyone starts with medication, and for many that is where it ends. Where it stops working, the established procedures are stereotactic radiosurgery, percutaneous rhizotomy and microvascular decompression — all of which Dr Tung performs. Seeing a neurosurgeon first does not mean going straight to an operation.
A specific anticonvulsant is the established first-line treatment and is often dramatically effective — pain can stop within days. Ordinary painkillers do not work here, for the same reason they do not work in other nerve pain.
Over years, some people find the effect fades or the side effects become limiting. That is the usual reason for moving on, rather than the drug failing outright.
Focused radiation delivered precisely to the trigeminal nerve root, without an incision and without general anaesthetic. Relief builds over weeks to months rather than immediately.
This is within Dr Tung's practice — stereotactic radiosurgery and radiotherapy are among his listed procedures.
Treatment delivered to the nerve through a needle passed through the cheek, interrupting the pain fibres. Relief is usually immediate. Because the approach deliberately affects sensation, some numbness is expected, and the effect can wear off over years.
The operation that addresses the cause rather than the signal: the offending blood vessel is separated from the nerve and held away with a small cushion. It offers the most durable relief of the surgical options and, unlike the others, does not rely on damaging the nerve.
It is open surgery inside the skull, so it suits people who are otherwise well and whose imaging shows a clear vessel against the nerve. Whether it is the right choice for you is a discussion to have in person.
This is among Dr Tung's procedures, which means the full range — medication, radiosurgery, percutaneous treatment and decompression — is available without being referred onwards.
The usual path is a dentist, then a doctor, then a neurologist, then — once medication has stopped working — a neurosurgeon. That can take years, and each step is a new consultation explaining the same history again.
There is no need for it. Dr Tung prescribes the first-line medication as well as performing the procedures, so starting here does not commit you to surgery and does not skip a step. It removes one.
Facial pain has several causes — dental, sinus, cluster headache, referred from the neck, post-shingles, and this. They are distinguishable on examination, and getting it right at the outset is what prevents unnecessary dental work and years of treating the wrong thing.
Imaging answers two questions: is a blood vessel sitting on the nerve, and is there anything else causing this. The first determines which procedures are possible later. The second occasionally finds something that needs treating now, regardless of the pain.
Waiting until medication fails to ask those questions delays both answers by years.
The first-line drug works well but requires the dose to be built up carefully and monitored. Knowing the difference between a dose that needs adjusting and a treatment that is genuinely failing is a judgement call — and it is the judgement that determines whether you spend another year on tablets that are no longer working.
If medication does stop working, the next conversation happens with someone who already knows your history and has already seen your imaging. No new referral, no repeating everything, no waiting to be seen again.
That is a common and telling history. Pain that persists after dental treatment, or that was never quite explained by the tooth, should be assessed as possible nerve pain before any further dental work.
It is not life-threatening, but it is severe, and it affects eating, speaking and sleep. It also occasionally signals something pressing on the nerve, which is why imaging is part of the assessment.
Probably not, at least initially. Most people respond well to medication. Procedures become relevant where the medication stops working or the side effects cannot be tolerated.
Because this is nerve pain rather than pain from damaged tissue. Ordinary painkillers act on inflammation and injury, and there is none here — the nerve is misfiring.
It typically runs in periods of attacks separated by remissions, and those remissions can last months. Over time, attack periods tend to become longer and remissions shorter, which is why treatment is worth starting rather than waiting out.
No. Bring any dental records and imaging, and note what triggers an attack, how long each one lasts, and which part of your face is affected.
Neuropathic pain · Cluster headache · Cervicogenic headache · Post-herpetic neuralgia · Headaches (all types) · Neuromodulation
You do not need to have tried everything else first. Diagnosis, imaging and medication all start here — and if a procedure is ever needed, there is no referral to wait for.
