What is Facial Neuralgia: Causes, Symptoms, Treatment, Surgery, Diagnosis

Facial neuralgia is a condition characterized by facial pain that usually occurs as a sudden, shock like pain. It is actually the facial nerve pain that leads to facial neuralgia and pain in the face is mainly experienced in the facial region and the structures associated with it. Facial neuralgia can originate from nerve disorders, may occur with increasing age or may be a result of some other condition.

Facial neuralgia, when caused by trigeminal nerve involvement, is also termed as trigeminal neuralgia or tic douloureux, in which a person experiences sharp, shooting facial pain. This may be seen more often in elderly women and in those who have a history of injury to the neck, face, jaw or head. Facial neuralgia is believed to be originating from compression of nerve either due to growing structures, disorders of the arteries or veins around the nerve. However, some people with compressed nerve may not experience facial neuralgia, while some do.

Facial neuralgia can be caused by inflammation, infection or injury to the nerve. The most commonly affected nerves include trigeminal nerve, which supplies the face and the head or sometimes the facial nerve, which supplies the small structures of the face. Facial neuralgia is often a result of involvement of trigeminal nerve leading to pain in the face. Trigeminal nerve, being the largest nerve in the head, is involved in sending pain signals and sensations to the face, corners of the eyes, cheeks and the jaws.

While facial neuralgia can also occur without any apparent cause, certain causes and trigger factors of facial neuralgia have been identified. Some of the possible common causes of facial neuralgia include:

• Oral Conditions – Tooth and other related dental structures are closely placed around the area through which the nerves of the face pass. Any inflammation, infection or abscess in the teeth can cause pain in the face or facial neuralgia. Tooth abscess, dental carries extending deep to cause nerve pain, tooth extraction or other dental problems can cause facial neuralgia. Infections in the oral cavity, gum abscesses or similar problems can cause nerve pain and facial neuralgia. Inflammation and infection of the salivary glands.
• ENT (ear, nose and throat) related conditions – Nasal conditions and inflammation of the paranasal sinuses can cause pain in the facial region, particularly below the cheek bone and above the eye ridges. Sinusitis, rhinitis, deviated nasal septum and other nasal conditions often cause facial pain and can contribute to facial neuralgia. Ear related conditions causing inflammation of structures or injury to the nerves too can cause facial neuralgia. Acoustic neuroma is a type of tumor, which grows around the nerve close to the brain and the ear; this too can be a cause of facial neuralgia.
• Viral Infections – Viral infections can commonly affect the ear, nose and throat causing common cold, throat infections, etc. which can cause pain in the face and appear like facial neuralgia. Certain viral infections also tend to affect the nerves and cause neuralgic pain in the face leading to facial neuralgia. Infection caused due to herpes virus, mumps infections, which can cause swelling and inflammation of the parotid glands too can be a cause of facial neuralgia.
• Temporomandibular Joint (TMJ) Disorders Can Cause Facial Neuralgia – Temporomandibular joint is the jaw joint located at the junction of both the jaws, just behind the ears. Any inflammation, injury or degeneration of the TMJ can cause pain originating from the joint, which can extend over the face causing facial neuralgia. Certain injuries to the TMJ may result in dislocation of the joint, damage to the ligaments or the soft structures present in and around the joint. This can damage the nerve near it or cause entrapment of the nerve causing facial neuralgia.
• Trigeminal Neuralgia – Facial neuralgia can be originated from involvement of the fifth cranial nerve called trigeminal nerve. This can result from all causes of facial pain including facial trauma, injury to the nerve during sports, accidents or surgeries and is an important cause of facial neuralgia. Over a period of time and continued pain, the protective coating over the trigeminal nerve may get damaged causing facial neuralgia more often.
• Facial Neuralgia Caused Due to Nerve Related Conditions – Conditions affecting the nerves, causing nerve damage can lead to facial neuralgia. Conditions that affect the spinal cord, brainstem or the central nervous system too can cause damage to the nerve and result in facial neuralgia. For e.g. multiple sclerosis.
• Medical Conditions – Complications of certain medical conditions like diabetes or other neuropathies, which cause nerve damage, can lead to facial neuralgia. Other conditions like glaucoma (which is increase in intraocular pressure) can damage the optic nerve and contribute to the facial pain in facial neuralgia. Rheumatic conditions and musculoskeletal problems that affect the muscles making them stiff and painful, too can sometimes exert pressure on the nerves supplying the face, especially when the head, neck and shoulder muscles are involved. This can cause facial neuralgia and lead to pain in face. Conditions like Polymyalgia rheumatica, fibromyalgia can contribute to facial neuralgia in this way. Sometimes conditions like hypoparathyroidism may also cause facial neuralgia.
• Others – Other causes that can lead to facial pain or facial neuralgia also need to be considered. Cysts or sacs filled with fluid, can exert pressure on the nerve, causing pain in face, leading to facial neuralgia. Tumors, lumps or growths of any kind too can cause facial neuralgia and affect the nerve supplying the face. Deformities or damage to the arteries and veins close to the nerves of the face can cause damage to the nerves causing facial neuralgia. For e.g. conditions like arteriovenous malformation. Temporal arteritis is a condition in which the arteries supplying the head, called temporal arteries get inflamed. This often presents with severe headache and can cause pressure or damage to the nerve and can cause facial neuralgia.

Symptoms of facial neuralgia are experienced by every person in a different manner. The presentation of facial neuralgia in different people may also depend on their age, condition and the causes of facial neuralgia in them.

People experiencing facial neuralgia often complaint of sudden, intermittent pain in face, which may be very irritating at times. Many people with facial neuralgia may complain of sudden facial pain mostly on one side or lower part of the face or sometimes on both sides of the face, mostly at different times. Facial neuralgia arising from specific causes may be experienced in the areas supplied by the particular nerve that is affected.

Pain is commonly felt in the scalp, forehead, over or around the eyes, close to the ears or the jaw joint, near the cheeks, jaws and upper or lower lips. If the causes of facial neuralgia include those related to tense muscles, pain may also extend around the ears or to the neck region.

Facial pain in facial neuralgia is commonly experienced as a sharp, burning pain, which may begin all of a sudden, spread over a specific area and subside in sometime. People generally complain of aching, burning sensation with pain in the affected areas and spasm like facial pain in facial neuralgia.

Pain may be aggravated when the person uses the affected area depending on the cause of facial neuralgia. These may include activities like touching ears, temple areas, forehead or washing or wiping face, brushing teeth, touching the face or wearing make up on the face. If the cause of facial neuralgia is related to the temporomandibular joint, pain may be triggered by opening or closing the jaw, yawning, screaming or singing. Facial pain in facial neuralgia can also be triggered by chewing, swallowing and similar activities. Sometimes, simply touching or scratching the scalp too can trigger facial neuralgia.

Facial neuralgia may have different presentation in most people. While some may experience pain in the same area again and again, for some the pain may begin in one spot and slowly spread to the nearby areas or even wider. Bouts of facial neuralgia may continue with the same intensity in some while it may increase in intensity over a period of time. When facial neuralgia covers larger areas and increases in intensity with time, it may be more debilitating.

Pain in facial neuralgia can interfere with a person’s daily activities like talking, eating and sleeping. Facial neuralgia can make a person experience pain often and affect daily routine and even affect a person’s sleep. Deprivation of sleep in turn can increase the problem of facial neuralgia. However, the episodes of facial pain may be rare during the night when the person is sleeping or resting, facial neuralgia can cause general disturbance in the mind of a person. Owing to the facial pain in facial neuralgia people may begin to avoid regular activities, more because of the fear associated with forthcoming facial neuralgia.

Facial neuralgia pain is often intermittent and can keep bothering the person. The nature of facial pain in facial neuralgia can vary from person to person and may change even in the same person. Pain in facial neuralgia usually varies from sudden, stabbing, sharp pain in face to aching, constant and continuously irritating facial pain.

Sometimes the pain is intermittent while at other times it may remain constant for some time. It often lasts for few seconds but may last even longer at times. Bouts or episodes of facial neuralgia or facial pain usually stay for few seconds to minutes. Such bouts or attacks of facial neuralgia can last for days, months or weeks, at the same time there may be long periods when the person won’t have any symptoms at all.

Diagnosis of facial neuralgia begins with taking a thorough history of the person. History may reveal conditions that can be possible causes of facial neuralgia. Any previous injury or trauma to the head, face or neck area must be enquired and appropriately evaluated. Previous history of surgeries, ophthalmic, ear or dental treatment and similar other procedures or medical treatment is equally important. Information about the clinical presentation and symptoms of facial neuralgia too can give a clue towards the diagnosis of facial neuralgia.

The initiation of symptoms of facial neuralgia, patient’s complaints and the related history must be properly evaluated. Assessment of facial neuralgia mainly considers the type of facial pain, its location, the nature of facial pain and the duration for which it lasts. The number of attacks and their repetition is considered. The triggers of facial neuralgia in a person are important too and must be discussed.

Considering these factors, the physician may perform clinical examination of the face. Clinical examination of the face is an important part in the diagnosis of facial neuralgia. The physician often examines the face, touches various areas, assess the functioning of the parts and evaluates muscle control in the area. This can give an idea about the possible nerve involved, which is the cause of facial neuralgia and the extent to which it affects the face.

Certain tests to assess the symmetry of the face may be performed, reflexes may be checked to get an idea of the possible causes of facial neuralgia. Causes of facial neuralgia are kept in mind considering the history of the patient and the possibility of nerve compression is determined with the help of these tests. The underlying causes of facial neuralgia are mostly manageable, however, some causes of facial neuralgia may be serious and may need immediate medical treatment. History taking and primary assessment of the patient gives an idea and appropriate investigations for facial neuralgia may be ordered.

Investigations may be mainly done to rule out possible serious causes of facial neuralgia. Also, if there is a history of previous injury or surgery, certain investigations may be considered to assess the status of injury or surgery, its involvement in causing facial neuralgia or to consider other associated causes of facial neuralgia. Some of these investigations include

• Magnetic Resonance Imaging (MRI) – This scan is considered as one of the most effective in detecting injuries or any damage to the tissues, soft tissue involvement or causes of facial neuralgia related to nerves and blood vessels. It also helps to determine the presence of growths and hence is widely used in diagnosis of facial neuralgia. MRI is ordered for the area possibly involved in the causes of facial neuralgia. MRI helps to detect many abnormalities that can cause facial neuralgia, including multiple sclerosis, injuries, ligaments or soft tissue injuries, nerve compression, tumors or other forms of growths causing nerve compression and facial neuralgia. It also helps to determine the involvement of intervertebral discs in case of cervical spine or when neck is involved along with other head or facial structures. Blood clots, arteriovenous malformations and other disorders of the arteries and veins, which can be the causes of facial neuralgia can be determined by the use of specialized MRI scans.
• Electromyography (EMG) – This too is an important test, where nerve compression is suspected and helps in confirming the diagnosis of facial neuralgia. This diagnostic tests is performed to assess the muscles and whether the nerve signals passing through them are healthy. It is performed when symptoms include muscle weakness, muscle pain, numbness or tingling in the supplied area. In facial neuralgia, the signals are passed to check electrical activity in the nerves supplying the face. In this test, small electrodes are placed on the area supplied by the nerve and the signals are passed through the muscles to assess the strength. The results obtained from EMG can help in diagnosis of facial neuralgia or help to rule out other related conditions.
• Nerve Conduction Study (NCS) – This test is often performed along with electromyography to study the nerve impulses passing through the nerve. It helps to determine whether the nerve is functioning normally. In facial neuralgia, possible nerves that may be involved may have to be tested depending on the symptoms of facial neuralgia and the associated history.

Diagnosis of facial neuralgia can be made by a comprehensive approach that includes all of the above examinations, tests and investigations for facial neuralgia.

Treatment of facial neuralgia mainly depends on the cause of facial neuralgia. In most cases, involving the muscles and nerves, medications may be prescribed. Although facial neuralgia is a pain condition, pain killers may not be helpful as it is the pain related to the nerve. However, in conditions where injury or inflammation is caused, anti-inflammatory medicines maybe considered. For treatment of facial neuralgia in particular, medicines like muscle relaxants and anticonvulsants are commonly prescribed.

Muscle relaxants help to relax the tense muscles, thereby reducing muscular pain and also helps in relieving the entrapped nerves, which helps to ease facial neuralgia. Anticonvulsants help to control pain and are useful in treatment of facial neuralgia. These medicines may cause drowsiness, nausea and dizziness and the hence the dosage must be adjusted accordingly and constantly monitored. These medicines may also be combined with nerve regeneration medicines to aid the treatment of facial neuralgia. When these medications are taken for a longer duration, they may seem ineffective, for which the doses may have to be increased or another similar medicine is considered. Additionally, vitamin and other nutritional supplements may be considered in some cases.

In some patients, who do not respond to medical treatment of facial neuralgia or in those with progressive facial neuralgia, other treatment options may have to be considered.

Surgery for facial neuralgia may be considered depending on the cause of facial neuralgia. The aim of surgical treatment for facial neuralgia may be to release the nerve from compression, remove the structures causing nerve compression or to cut the nerve to reduce pain signals.

If tumors or similar growths are the cause of facial neuralgia, they may have to be operated and removed.

In case of trigeminal neuralgia, rhizotomy or rhizolysis is performed in different ways to treat facial neuralgia. These are aimed at damaging the trigeminal nerve, which helps to block the pain signals.

Some Surgeries to Treat Facial Neuralgia Include:

• Microvascular Decompression – This surgical procedure includes removing or shifting the blood vessels in close proximity to the nerve root. This is done to treat facial neuralgia originating from trigeminal nerve compression. While this procedure to treat facial neuralgia may help to reduce pain in most cases, facial pain may reappear after few years in some cases. Some risks of this procedure include damage to the nerve or blood vessels causing facial weakness, reduced hearing or stroke.
• Radiosurgery – In this treatment for facial neuralgia, a focused dose of radiation is directed at the root of the trigeminal nerve. This may be performed as Gamma Knife radiosurgery or with use of linear accelerator systems.
• Sensory Rhizotomy – This procedure is performed in trigeminal neuralgia or facial neuralgia caused by trigeminal nerve problems. In this procedure, the trigeminal nerve sensory root is cut at the point where it gets connected to the brainstem, but the motor root is preserved to enable functioning. As the sensory root of the nerve is cut, it may cause facial numbness and hence, this procedure to treat facial neuralgia is considered only when all other treatment have failed.
• Peripheral Neurectomy – In this procedure depending on the painful area, the corresponding part of the trigeminal nerve is cut through a small incision.

Apart from these, there are certain procedures for treatment of facial neuralgia, or rhizotomy which can be performed include:

• Glycerol Injection – In this treatment for facial neuralgia, an injection of sterile glycerol is injected at root of the trigeminal nerve and at the area, where the trigeminal nerve bifurcates into its branches, which further supply the different areas on the face. This blocks pain signals and helps to relieve facial neuralgia.
• Balloon Compression – In this procedure, a balloon catheter is inserted into trigeminal nerve, through the cheek. The balloon is then inflated to create pressure and injure the pain fibers of trigeminal nerve, thus blocking pain signals.
• Radiofrequency Rhizotomy or Thermal Lesioning – In this procedure, heating current or radiofrequency is used to damage the trigeminal nerve, thus reducing facial pain in facial neuralgia. It is also known as Percutaneous Stereotactic Radiofrequency Rhizotomy or RF ablation or RF lesion.

Some people with facial neuralgia may find complementary therapies helpful. These include

Physiotherapy – Physical therapy makes use of various modalities depending on the cause of facial neuralgia. These include like ultrasound, nerve stimulation and others, which may help to relax tense muscles, reduce nerve pain signals and relieve facial pain. This may be followed by therapeutic exercises to regain muscle control and maintain muscle strength.

Alternative Medicine – Many find alternative therapies like homeopathy, Ayurveda, acupuncture or other healing techniques helpful. Yoga therapy and stress management, relaxation techniques may also be helpful. Meditation and breathing techniques are believed to help in managing pain conditions.

Nutrition Therapy – Appropriate diet and lifestyle management may help to manage facial neuralgia and prevent debilitating pain.

Counseling and Psychotherapy – Support from a counselor can help as facial neuralgia can be debilitating and when it interferes with daily activities, a person may find it difficult to cope. Interacting with family, friends and professional therapists can help to deal with the situation better.

While most of these can help to relieve pain in facial neuralgia, it is advisable to take medical opinion. If these treatment options for facial neuralgia do not show any improvement or if there is worsening of symptoms, it is better to seek immediate medical care.