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By Prodyut Das

Trigeminal Neuralgia Pain

by Prodyut Das
(New Delhi, India)

Trigeminal Neuralgia (Tic Douloureux) The Suicide Disease

This is a common disorder of middle age and later life, consisting of paroxysms of intense, stabbing pain in the distribution of the mandibular and maxillary divisions (rarely the ophthalmic division) of the fifth cranial nerve. The pain seldom lasts more than a few seconds or a minute or two, but it may be so intense that the patient winces involuntarily; hence the term tic. It is uncertain whether the tic is reflexive or quasi-voluntary.

The paroxysms recur frequently, both day and night, for several weeks at a time. Another characteristic feature is the initiation of a jab or a series of jabs of pain by stimulation of certain areas of the face, lips, or gums, as in shaving or brushing the teeth, or by movement of these parts in chewing, talking, or yawning, or even by a breeze—the so-called trigger zones .

Sensory or motor loss in the distribution of the fifth nerve cannot be demonstrated, though there are minor exceptions to this rule. In addition to the paroxysmal pain, some patients complain of a more or less continuous discomfort, itching, or sensitivity of restricted areas of the face, features regarded as atypical even though not infrequent. In studying the relationship between stimuli applied to the trigger zones and the paroxysms of pain, the latter are found to be induced by touch and possibly tickle rather than by a painful or thermal stimulus. Usually a spatial and temporal summation of impulses is necessary to trigger a paroxysm of pain, which is followed by a refractory period of up to 2 or 3 min. This suggests that the mechanism of the paroxysmal pain is in the nature of allodynia, a feature of other neuropathic pains.


The diagnosis of tic douloureux must rest on the strict clinical criteria enumerated above, and the condition must be distinguished from other forms of facial and cephalic neuralgia and pain arising from diseases of the jaw, teeth, or sinuses. Most cases of trigeminal neuralgia are without obvious assignable cause (idiopathic), in contrast to symptomatic trigeminal neuralgia, in which paroxysmal facial pain is due to involvement of the fifth nerve by some other disease: multiple sclerosis (may be bilateral), aneurysm of the basilar artery, or tumor (acoustic or trigeminal neuroma, meningioma, epidermoid) in the cerebellopontine angle. It has become apparent, however, that a proportion of ostensibly idiopathic cases are due to compression of the trigeminal roots by a tortuous blood vessel, as originally pointed out by Dandy. Jannetta has observed it in most of his patients and has relieved their pain by surgical decompression of the trigeminal root in the form of removing the offending small vessel from contact with the proximal portion of the nerve. Others have declared a vascular compressive causation to be less frequent. Each of the forms of symptomatic trigeminal neuralgia may give rise only to pain in the distribution of the fifth nerve, or it may produce a loss of sensation as well.


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