Tic Douloureux

Tic Douloureux Overview

Tic douloureux or trigeminal neuralgia is a severe, stabbing pain to one side of the face. It stems from one or more branches of the nerve that supplies sensation to the face, the trigeminal nerve. It is considered one of the most painful conditions to affect people.

The pain usually lasts from a few seconds to a few minutes. It may be so intense that you wince involuntarily, hence the term tic. There is usually no pain or numbness between attacks and no dysfunction of the muscles of the face.

Most people feel the pain in their jaw, cheek, or lip on one side of the face only. Pain is usually triggered by a light touch of the face or mouth on the same side as the pain. The pain is so severe that people can become afraid to talk, eat, or move during periods of attacks.

Although a flurry of attacks can last for weeks or months, there are usually periods of months or even years that are symptom-free. The pain of tic douloureux is usually controlled with medications or surgery.

Tic douloureux is generally a disease of middle age or later life. Women are affected more often than men. People with multiple sclerosis are affected much more frequently than the general population.

Tic Douloureux Causes

The cause of tic douloureux is unknown. There are a number of theories as to why the trigeminal nerve is affected.

The most commonly accepted theory is compression of the trigeminal nerve, usually by a blood vessel, causing it to become irritated. This irritation causes the outer covering of the nerve (the myelin sheath) to erode over time. The irritated nerve then becomes more excitable and erratically fires pain impulses.

Tumors and bony abnormalities of the skull may also press on and irritate the trigeminal nerve. In addition, trauma, infections, and multiple sclerosis can also damage the trigeminal nerve.

Tic Douloureux Symptoms

The main symptom of tic douloureux is a sudden, severe, stabbing, sharp, shooting, electric-shock-like pain on one side of the face. Because the second and third divisions of the trigeminal nerve are the most commonly affected, the pain is usually felt in the lower half of the face.

The pain comes in intermittent episodes that last from a few seconds to a few minutes. There may be many episodes of pain each day. There is usually no pain between episodes.

The flurry of pain episodes may last from a few weeks to a few months, followed by pain-free periods of months to even years. Generally, the episodes become more frequent and more resistant to treatment with medications over time.

The attacks of pain are often initiated by physical stimulation of a trigger point on the same side of the face as the pain. Trigger points can be anywhere on the face or in the mouth or nose. They are generally not in the same place as the pain. Stimuli that can initiate the pain include talking, eating, brushing the teeth, or even cool air on the face. There is no loss of taste, hearing, or sensation in someone suffering from tic douloureux.

When to Seek Medical Care

Call your doctor when the prescribed medications are not controlling the pain, or if you develop new symptoms. Because tic douloureux is a pain-only syndrome, the development of new symptoms may warrant additional evaluation.

Go to a hospital's emergency department if you experience symptoms such as fever, redness of your face, or dizziness. These symptoms may not be related to your condition and may signify another illness. If your prescribed medication is not relieving the pain and your doctor is not available for advice, go to the hospital.

Exams and Tests

There is no single medical test to diagnose tic douloureux. The diagnosis is made based on the description of the pain, physical examination, and exclusion of other causes of facial pain.

The pain is unique. A history of bursts of shooting pain in one side of the face along with a trigger zone will give the doctor good clues to the cause of your pain.

The physical examination is normal in tic douloureux. If numbness, decreased hearing, dizziness, visual changes, or dysfunction of the muscles of the face is found, then other disorders may be considered. Additionally, other causes of facial pain such as a sinus infection, dental infection, or a jaw disorder, such as TMJ, can often be found by physical examination.

Special X-ray images, such as a CT scan or MRI of the head, can look for other causes of facial pain. They can also help delineate blood vessels or tumors that might be pressing on the nerve and irritating it.

Tic Douloureux Treatment

Self-Care at Home

There are no effective home treatment remedies for tic douloureux. Treatment should be guided by a physician. The role of the doctor is to ensure the diagnosis, begin appropriate therapy, and coordinate any potential need for consultants. In most cases, effective treatment will require only medications. Uncommonly, surgery will be recommended.

Medical Treatment

The primary treatment of tic douloureux is medication to control the pain. Surgery may be necessary when drug therapy is not effective or side effects from the medications are not tolerable.

Medications

A number of medications can be effective in helping control the pain of tic douloureux. The most commonly prescribed medications are anticonvulsants (seizure medications). Anticonvulsants help to stop the irritated trigeminal nerve from firing pain impulses.

• The most frequently prescribed anticonvulsant medication for tic douloureux is carbamazepine (Tegretol). Oxcarbazepine (Trileptal), gabapentin (Neurontin), and lamotrigine (Lamictal) may also be effective, These medications are generally started at a low dose and then increased until pain is controlled or side effects occur. Common side effects include drowsiness, dizziness, double vision, and nausea. Rarely, serious liver or bone marrow problems can occur.
• [Baclofen (Lioresal), a muscle relaxant, may be useful for some people who either do not respond to anticonvulsants or who suffer serious side effects.
• An antipsychotic medicine pimozide (Orap) has been helpful in some cases as well.
• Opioid pain medications can be useful during episodes of severe pain.
• Botox injections have been shown to offer significant pain relief.

Medication is at least partly effective for most people who suffer with tic douloureux. For the rest, drug therapy either fails to provide adequate pain control or adverse side effects are intolerable. Unfortunately, many people who initially respond to anticonvulsants eventually develop resistance to the medications.

Surgery

When pain cannot be controlled with medication, surgical options should be discussed with a neurosurgeon. Surgery could range from simple injections of anesthetic into the trigeminal nerve to complex procedures that must be performed in the operating room. In general, the more complex procedures provide longer-lasting pain relief but with greater potential for more serious complications.

Next Steps

Follow-up

If you are diagnosed with tic douloureux, your doctor may refer you to a neurologist or neurosurgeon for management of the pain.

Some of the medications used to treat tic douloureux may affect your blood counts and liver function, so it is important to have these levels monitored as instructed by your doctor.

After surgery, watch for signs of infection such as redness, discharge, or fever.

Outlook

Although pain from tic douloureux can go away without treatment for months to years, the disorder is usually progressive. Attacks can become more frequent over time. There are no long-term medical consequences of the disorder. Tic douloureux is purely a pain syndrome.

The pain of tic douloureux can almost always be controlled with either medication or surgery.

Most people with tic douloureux lead full, complete lives.

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