Electric shocks in the face from brushing your teeth. The description is the diagnosis.

TRIGEMINAL NEURALGIA

Trigeminal neuralgia causes electric shocks in the face, seconds long, triggered by touching your cheek or brushing your teeth. It is one of the few conditions in medicine where the description alone is close to diagnostic (enough to name the problem).

What are the symptoms of trigeminal neuralgia?

Trigeminal neuralgia is brief, paroxysmal (sudden-burst), electric-shock-like pain. It hits one or more divisions (branches) of the trigeminal nerve. It is set off by innocuous stimuli (things that are normally harmless). The attacks last seconds to under two minutes. There is usually a refractory period afterward (a stretch when another attack cannot be set off). Between attacks, most people are pain-free.

Constant burning facial pain is a different entity. Facial pain that lasts hours is a different entity. Bilateral (both-sided) facial pain in a young person raises multiple sclerosis, and that needs to be ruled out. Getting the classification right is the whole of the treatment decision. That is why the European Academy of Neurology guideline gives it as much attention as it does.

Why it appears on a neck website

Two reasons, both practical. First, the trigeminal system and the upper cervical roots meet at the same brainstem nucleus (a relay center in the brainstem). That is why upper cervical pathology (a problem in the upper neck) can cause facial pain. It is also why facial pain patients are sometimes sent to us. Second, people with facial pain pile up a long list of negative tests. They arrive looking for anybody who will work the differential (the list of possible causes) properly.

We are not the final stop for classical trigeminal neuralgia. We are often the service that establishes it is trigeminal neuralgia, rather than one of these: a cervical referral (pain sent from the neck), a cervicogenic headache, a dental problem or a temporomandibular (jaw joint) disorder. That distinction is where most of the wasted years go.

How is trigeminal neuralgia diagnosed?

• MRI, and in particular sequences that show the trigeminal root entry zone (where the nerve root enters the brainstem). That is because neurovascular compression (a blood vessel pressing on the nerve) and secondary causes both need to be found.
• Neurological examination — sensory loss (loss of feeling) in the trigeminal territory (the area the nerve supplies) points away from the classical form. It points toward a secondary cause.
• A dental assessment where it has not been done. That is because dental pathology (tooth problems) mimics this, and irreversible dental work done on trigeminal neuralgia is a known harm that can be avoided.
• A cervical examination, which is the part that is usually missing.

How is trigeminal neuralgia treated?

Carbamazepine and oxcarbazepine are first-line medical treatment. The response to them is typically good. It is good enough that a complete lack of response is itself a reason to revisit the diagnosis. Say medication fails or is not tolerated. Then microvascular decompression and the ablative and radiosurgical options exist and have a real evidence base.

Our role sits before that. We confirm the diagnosis. We address any cervical or myofascial (muscle and connective tissue) component that is adding to it. And we make sure the referral that follows is the right one rather than the first one. We do not route anybody straight to a surgical opinion without working the diagnosis first. Facial pain is the area where that policy earns its keep most often.

The overlap nobody mentions

A person can have classical trigeminal neuralgia and a myofascial or upper cervical pain problem at the same time. Say the shocks are controlled on medication and a background ache remains. That leftover ache is frequently the second problem — and it is treatable. Blaming it on incomplete control of the neuralgia leads to dose increases that do nothing.

The trigger map is worth writing down

Note exactly what sets it off and where the trigger zone is. It may be a specific patch of cheek, a tooth, the gum, the corner of the lip, cold air, chewing, shaving, brushing. That map identifies the affected division. It is more useful for diagnosis than most of what gets ordered.

It also helps in a practical way. People stop eating and stop brushing on the affected side. The weight loss and dental decline that follow become their own problems on top of the pain.

Why the diagnosis gets delayed

The first stop for facial pain is usually dental, because that is where facial pain sensibly starts. When exams and imaging of the teeth are normal, the path forward is often unclear. People cycle between services while the attacks continue.

The description of the pain — brief, electric, triggered by light touch, with pain-free intervals — is close to diagnostic on its own. It is asked for less often than it should be. It is the first thing we ask about.

Can trigeminal neuralgia be caused by MS or a tumor?

Trigeminal neuralgia can be classical, idiopathic (no known cause), or secondary to a lesion that can be found. Multiple sclerosis and posterior fossa tumors (tumors at the back of the brain) are the ones that must not be missed. The classification systems separate these on purpose. That split drives everything that follows.

Watch for sensory loss on exam, bilateral symptoms, onset under forty, or any added neurological sign. Each one shifts the odds toward a secondary cause. Those findings turn imaging from good practice into an urgent need.

What helps while you wait for a diagnosis?

Practical steps matter more here than in most pain conditions. That is because the triggers are the activities of daily life. A soft diet during a bad period. Lukewarm rather than cold water. A scarf across the face in wind. An electric razor. Chewing on the unaffected side.

None of that treats the condition. All of it makes the wait until treatment works survivable. Weight loss and dental neglect during an uncontrolled period cause real secondary harm. They are worth heading off on purpose.

What people ask about facial pain

Is it a brain tumor?

That is what most people are afraid to ask. Secondary causes exist. That is exactly why imaging is part of the workup rather than optional. And the large majority of scans do not show one. The occipital nerve block.

Could it be my teeth?

It could, and it also frequently is not. That is why irreversible dental work should wait until the diagnosis is settled. Extractions done on undiagnosed trigeminal neuralgia are a well-documented problem. TMJ, or the neck?

Why do the shocks come from touching my face?

Light touch triggering severe pain is the hallmark of the condition. It is a genuine feature of how the nerve is behaving, not sensitivity or exaggeration. How a cervicogenic headache is identified. Brief electrical pain is a nerve firing, and the trigger is diagnostic.

Will I need surgery?

Many people are controlled on medication for years. Surgery is for when medication fails or cannot be tolerated. It is a decision made with a secure diagnosis in hand. The occipital nerve block.

What causes trigeminal neuralgia?

Doctors sort it into three groups: classical, idiopathic and secondary. In the secondary form a specific lesion is behind it. Multiple sclerosis and tumors at the back of the brain are the ones that must not be missed. That is why the MRI looks closely at the spot where the nerve root enters the brainstem. It checks for a blood vessel pressing on the nerve and for any secondary cause.

How do I get rid of trigeminal neuralgia pain?

The first-line medicines are carbamazepine and oxcarbazepine, and the response to them is usually good. It is reliable enough that no response at all is a reason to recheck the diagnosis. Say medicine fails or cannot be tolerated. Then microvascular decompression and the ablative and radiosurgical procedures have a real evidence base. A background ache that stays after the shocks stop may be a second, treatable problem.

What foods should I avoid with trigeminal neuralgia?

Chewing and cold are common triggers. So the goal is to take the trigger out of eating, not to stop eating. During a bad stretch, a soft diet, lukewarm rather than cold drinks and chewing on the unaffected side all help. Keep eating and keep brushing. People who stop lose weight and develop dental problems that pile on top of the pain.

Related reading

• TMJ, or the neck?
• Cervicogenic headache
• Occipital nerve block
• Temporal arteritis
• CRPS
• Sternocleidomastoid spasm