‘Excruciating facial pain leaves me feeling like a zombie’

Dear Dr James,

“For the past 18 months I have suffered intermittent bouts of an excruciating, electric-shock like pain through the left side of my face that leaves me feeling like a zombie. 

“The neurologist told me this was ‘absolutely typical’ of trigeminal neuralgia, for which he prescribed Tegretol. This initially worked well, but the spasms have returned and he now advises I have an operation on the nerve. It fills me with trepidation – why does this keep happening?”

Dear Reader,

“Trigeminal neuralgia (TN) is so named as it involves the facial nerve whose three (trigeminal) branches provide sensation around the eye and to the cheek and jaw. 

“This is an ancient affliction, first described in the second century AD by the Greek physician Aretaeus of Cappadocia. The famed Enlightenment philosopher (and doctor) John Locke offers a vivid description from 1677, as experienced by his patient the Countess of Northumberland: “An attack of such violent and exquisite torment that it forces her to cry out, as if a flash of fire all of a sudden shot through the affected parts. Speaking is apt to put her into an attack, and when opening her mouth to eat or touching her gums”.  

“Here he emphasises the salient features of the condition, where the spasms lasting just a few seconds three or four times a day may be triggered by the most seemingly trivial of stimuli – a gust of cold air, when shaving or teeth brushing, talking or eating. The constant apprehension that such simple activities may initiate an attack can be as psychologically debilitating as the pain itself. 

“These recurrent bouts of TN usually last for a few weeks, followed by a prolonged remission of months or even years – but in general their frequency and severity increase over time.” 

Causes

The onset of TN may be initiated by an episode of shingles affecting the facial nerve or be a feature of multiple sclerosis from damage to the nerve’s protective myelin sheath. In some cases, an MRI scan will reveal a benign tumour or vascular malformation, but for most the primary cause is pressure on the facial nerve by an aberrant artery or vein.

Medical treatment

The mainstay of treatment is the drug Tegretol, originally developed for the control of epileptic seizures and which works in a similar way by ‘damping down’ the nerve’s electrical impulses. 

Initially a small dose may be sufficient, but persistence or recurrence calls for its escalation limited by the (predictable) side effects of dizziness, drowsiness and nausea. Similar considerations apply to ‘second-line’ drugs such as Lamotrigine or Baclofen.  

Surgery

Definitive treatment entails the neurosurgical operation ‘microvascular decompression’, interposing a sponge-like Teflon pad between the aberrant blood vessel and the facial nerve. This is a major procedure with an 80% success rate – but carries a small but significant risk of loss of sensation or paralysis of the facial muscles.

Hypnosis 

Surprisingly, but worth considering, a reader reports her 70 year old mother was cured of her TN by hypnosis. “I sat in the room and watched in amazement as the hypnotherapist told her to touch her face with her finger. She hesitated as if she knew the pain would be intense but then began quite easily to stroke her nose and cheek. The relief was immediate”.