Trigeminal neuralgia pain is cruel. Facial nerve pain is characterised by sudden, sharp attacks of electrical shocks that last a few seconds, but can occur multiple times a day. It can be off set by something as small as touching your cheek in a hug. Trigeminal neuralgia treatment takes a team of dedicated healthcare workers, with you at the lead. You can get relief from your trigeminal neuralgia.

Even though trigeminal neuralgia is fairly uncommon, only 12 out of 100 000 people are diagnosed yearly, and you are unlikely to get it, it is better to equip yourself with the facts and know that there is help to trigeminal neuralgia relief.

Your facial nerve is the fifth of your 12 cranial nerves (CN V), with the anatomical name of Trigeminal Nerve. Cranial nerves directly communicate between your brain, face and neck. You have 12 pairs of cranial nerves for your body’s left and right sides.

The trigeminal nerve has three branches:

• ophthalmic
• maxillary
• mandibular

Your trigeminal nerve is a mixed nerve containing both sensory and motor fibres. All three branches have sensory fibres, while only the mandibular branch has motor fibres.

CN V originates from three sensory and one motor nucleus in your brain. The main trunk runs from your pons to your trigeminal ganglion which is located in your trigeminal cave, an indentation in your middle cranial fossa of the temporal bone. From this special cave the different branches go their separate ways.

Your ophthalmic branch runs through your cavernous sinus and exits from your superior orbital fossa. If you gently press your thumb pad underneath your brow, close to your nose, aiming upward, you can feel a tender, tiny cable there. This is part of the ophthalmic branch of your facial nerve. Your maxillary branch exits through your foramen rotondum. You can touch this exit by gently pressing straight backwards on the bony arch underneath your eye. And your mandibular branch exits through your foramen ovale, which we can’t touch as it lies behind your eye. All of these structures take up as much space as 5 ml of water, behind your eyeball.

Your trigeminal nerve carries sensory information of touch, temperature and pain from your face, sinuses, nose, mouth and teeth to your brain. The different branches carry these messages from the areas they supply.

By doing some imaginary facial war paint you can draw a line across the crown of your head from ear to ear, your trigeminal nerve serves the area in front of this line. Now draw another imaginary line right down the middle of your face across your nose to divide your face into left and right sides, your right trigeminal nerve supplies the right half and your left trigeminal nerve the left half of your face.

If you draw a skew line from the tip of your nose towards and underneath your eye, like you are applying eyeliner, and up to meet the crown line you have the area supplied by your ophthalmic branch. It also has sympathetic fibres that control pupil dilation and your lacrimal gland. If your ophthalmic branch is affected you may have issues with teary eyes and light sensitivity.

Draw the final line from the corner of your mouth, Joker style, to meet the ophthalmic line, your maxillary branch supplies the area underneath your eye to your upper lip.

Your mandibular branch supplies the area of your cheek, lower lip and chin. The sympathetic fibres also innervate your parotid gland, which secretes saliva. Your mandibular nerve also has motor fibres that innervate your temporalis, masseter and lateral pterygoid muscles. You use these muscles to chew and open your mouth to speak.

Nerves send information through our bodies by small electrical charges, known as action potentials. You can think of this as little waves travelling up and down your nerves.

A healthy nerve has a certain threshold of excitability. Signals below this threshold will not cause an action potential, almost like they are “too soft to be heard” by the nerve. These are known as subthreshold signals. Threshold or suprathreshold signals, that are equal to or above the nerve’s threshold will cause an action potential and the message is relayed. It works on an “all-or-nothing” principle, which means a suprathreshold signal, won’t cause a super response. The frequency of messages sent can become more, but the message’s amplitude and length remain the same.

These message waves travel because of ions, which change the nerve cell’s permeability. All action potentials have the same three phases of depolarization, overshoot and repolarization. Once a nerve cell is depolarized it releases a neurotransmitter that either stimulates or inhibits the next nerve cell.

Damage to a nerve makes it hyperexcitable and causes chronic firing, even when there are no messages to relay.

Even though the trigeminal nerve is safely protected within your skull, it isn’t guaranteed to be free from injury. Insult to the trigeminal nerve can happen from internal or external causes. Traumatic injuries from head trauma from a fall, accident and concussion can physically damage the nerve or the blood supply to the nerve. Vascular issues because of abnormalities of the blood vessels may lead to nerve damage too. Bone diseases, like Paget’s disease and Osteogenesis imperfecta, may lead to compression of the nerve root. These are considered classical etiologically established causes of trigeminal neuralgia.

Facial nerve pain can also be caused because of major neurological diseases, like multiple sclerosis or tumours. These are considered secondary etiologically established trigeminal neuralgia.

Unfortunately, 10% of all trigeminal neuralgia diagnoses have no identifiable cause and are termed idiopathic trigeminal neuralgia. It’s similar to what loadshedding has done to some house alarms. Sometimes there isn’t even a power failure and the alarm keeps going off.

Activities that can cause trigeminal neuralgia attacks:

• brushing teeth
• shaving
• vibration from facial treatments, razor or electric toothbrush
• rubbing/applying moisturiser
• touching the painful area
• putting on makeup
• chewing (eating)
• swallowing (drinking)
• speaking
• singing
• laughing
• being exposed to the wind
• sleeping on the affected side

The following questions are adapted from the Douleur Neuropathique en 4 (DN4) Questionnaire. This questionnaire is used to determine the presence of neuropathic pain. If you answer yes to 5 or more of the following questions your facial pain is caused by trigeminal neuralgia.

Even with all the advances in medicine, pain remains a subjective experience. What sends one person to the emergency room, another may endure for weeks. Someone who has felt nerve pain mostly ranks it as the worst pain that they have experienced, it is similar to toothache, sciatica and cervical radiculopathy.

Intensity

We make use of the visual analogue pain scale, where you rate your pain as a point out of 10. Trigeminal neuralgia is mostly described as 9 or 10 out of 10.

Duration

Trigeminal neuralgia pain “attacks”, where you experience the high intensity pain, mostly last for only a few seconds and never more than a minute. It can cause a subsequent dull ache that lingers in the face after or before an attack.

Frequency

The more frequent your attacks, the more severe your trigeminal neuralgia. Some people may experience a single attack a day, while others have up to 50 attacks every day. Treatment aims to reduce the frequency of your trigeminal neuralgia pain attacks.

Aggravating sensation/movement

The smaller the insulting movements or sensations that cause your attacks, the worse your trigeminal neuralgia pain. It is relatively easy to avoid the use of electric razors, toothbrushes or vibrating facial treatments, which are more aggressive aggravating movements. When a breeze, brush or talking causes pain attacks you have more severe trigeminal neuralgia pain.

Physiotherapists are uniquely qualified in that we have in depth anatomical knowledge, but also experience of biomechanics. It’s like having a race driver service your car. We are able to evaluate other causes of your facial pain by assessing your balance and cranial nerve function, neck muscles and joints and give you a diagnosis based on our findings.

We follow a structured plan to diagnose and determine the hierarchy of priority that your facial pain needs. Our physiotherapists can treat pain and explain the physiology to you. You will learn what to do, what to avoid and what can help ease your symptoms.

X-rays visualise bones, while ultrasound can show soft tissue structures. Because of the trigeminal nerve lies so deep, none of these will be able to show the nerve’s pathway. Therefor, no radiologic testing is routinely indicated for the diagnosis of trigeminal neuralgia. Your history, symptoms and clinical evaluation will confirm your diagnosis of trigeminal neuralgia pain.

A – Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve and fulfilling criteria B and C
B – Pain has at least 1 of the following characteristics: (1) intense, sharp, superficial or stabbing; or (2) precipitated from trigger areas or by trigger factors
C – Attacks stereotyped in the individual patient
D – No clinically evident neurologic deficit
E – Not attributed to another disorder

Trigeminal neuralgia is diagnosed based on history and symptom discription. MRI scanning can then differentiate between idiopathic trigeminal neuralgia, where no cause is found, or classical and secondary trigeminal neuralgia. Oher causes of facial pain, such as pressure on the trigeminal nerve from a tumor or multiple sclerosis also needs to be excluded.  If you experience hearing loss, facial paralysis and balance disturbances your physiotherapist will refer you to get the necessary imaging.

If you play the “wait-and-see” game you risk complications. Not necessarily structural tissue damage, but physiological changes that alters the way your nervous system processes sensory information. This leads to allodynia, where normally pain free stimuli, like stroking your cheek, can become excruciating.

Now avoidance, worry and anxiety can lead to an entire downward spiral into questions like “will this ever go away?”. It is best to not enter this cycle of pain and get the right treatment from the start. With intervention we aim to minimise the threat value for your nervous system, give you adequate pain relief with self strategies and guidance on medication use.

Waiting too long

The longer you wait, the bigger your chances of developing long term symptoms. It won’t go away by itself. Our physiotherapists will be able to refer you if any medication or imaging is necessary to establish the severity of your trigeminal neuralgia pain.

Our priority is to determine the extent of excitability or malfunctioning to your trigeminal nerve. We do this by taking a thorough history of your symptoms. Then, we test the integrity of your trigeminal nerve and compare your left and right sides.  We want to avoid subsequent attacks and protect the surrounding structures by correcting any compensation. This allows time for the trigeminal nerve to adapt and heal. Our practitioners bring on a change and monitor the results until it’s working, and then we magnify the effects to get even better outcomes.

The healing time for trigeminal neuralgia differs from person to person. How severe your symptom intensity and how long you have been experiencing your facial nerve pain greatly influences your healing time. Nerves tend to “hold grudges” and you may experience symptoms later as “pay back”. This is simply because your nerves are like your alarm system and are continuously on the lookout for possible threats and danger. Once injured the alarm system “remembers” this threatening situation and may cause flare ups to return from time to time. With proper treatment you should experience less intense and less severe flare ups until your trigeminal neuralgia is a small nuisance and not influencing your quality of life anymore.

Frequent treatments are ideal during the first 8 weeks of your rehabilitation, from then we can space your treatments to once monthly. Trigeminal neuralgia treatment requires patience and persistence, there is no quick fix.

• Your doctor can prescribe medication to ease your trigeminal neuralgia pain. This is not your standard treatment protocol that you would use for your neck muscle spasm and over the counter medication may not be effective. Anti-seizure and muscle relaxants are better options for facial nerve pain than anti-inflammatories and analgesia.
• Botox injections can be considered from your neurologist to induce muscle and nerve relaxation to ease your facial nerve pain.

Surgery for trigeminal neuralgia can be considered if non surgical intervention is unsuccessful. The most common procedure is microvascular decompression. This is done from an incision behind your ear where blood vessels are moved, cusioned or removed completely to avoid compression caused by change in vascular flow.

Trigeminal neuralgia surgery has the risk of long term effects, like weakness or numbness of your face or hearing loss. This procedure offers a 3 – 5 year relief period if successful and may be repeated again.

• Headache

Cervicogenic headaches can cause facial and scalp pain.

• C1/2 joint disorder

Whiplash or other injury to your high cervical spine can cause referred pain to your face and jaw.

• Vestibular neuritis

Vertigo and balance dysfunction, caused by a viral infection of the vestibulocochlear nerve (CN VIII), may also cause as facial pain.

• Bell’s Palsy

One-sided facial paralysis, caused by compression or inflammation of CN VII, can lead to facial pain.

• Sinusitis

Inflammation or infection can cause one sided facial pain because of congestion.

• Facial nerve pain
• Trigeminal disease
• Tic Douloureux
• Facial neuralgia
• Prosopalgia
• Fothergill’s disease
• Suicide disease