The symptoms are stabbing electric shock pain in areas of the face such as the cheeks, gum. Attacks last only a few seconds but several may occur in rapid succession. Pain usually occurs on only one side of the face and may be associated with squinting or twitching. There is little or no loss of feeling on the affected side. One area of the face e.g. the upper or lower lip becomes a trigger zone for the face. The slightest movement of this area e.g. by washing, shaving or talking may set off an attack. Tic doloureux is slightly more common in women, after the age of 40 years and in people with herpes zoster or multiple sclerosis. Tic doloureux is thought to be due to abnormal (epileptic) discharge of the trigeminal (or fifth) nerve, which is the nerve that provides sensation in the face. This is different from patients with epilepsy where the whole brain may discharge abnormally. Abnormal discharge may be due to irritation or injury to the trigeminal nerve. Such irritation may be due to compression by a blood vessel or any swelling that compresses the nerve in the area of the brain where it exits on the way to the face. Sometimes there may be no explanation for any irritation. Injury to the nerve may occur after a fracture of the jaw or any of the bones. It may also occur following surgery.
Some patients feel better by applying pressure to the area around the trigger zone. The best prevention is to take your anticonvulsant medications regularly. These medications prevent the abnormal firing of the trigeminal nerve. Take the medicines with food to prevent stomach upset.
Drugs that help control trigeminal nerve inflammation include a subcutaneous injection of the biologic drug Kineret as well as an intravenous (IV) or intramuscular (IM) injection of cortisone, plus an IV infusion of the anti-seizure drug Depacon combined with IV infusion of magnesium sulfate and IV mini bolus doses of Ketamine. Oral anti-seizure medications e.g. Trileptal, Topamax, Lyrica or Neurontin help prevent and treat the pain. Take the medications regularly. Some of these medications may decrease the production of blood cells so your physician may have to check your blood every few weeks. Occasionally some of these medications may produce a skin rash. Other medications that are used in treating the pain include muscle relaxants like Zanaflex or baclofen, antidepressants like Lexapro and strong pain relievers like hydromorphone or oxycodone. In addition to medications, heat destruction (thermocoagulation) or nerve block of the fifth nerve with local anesthetic, steroids or glycerol may provide good long-term relief. A side effect of these procedures may be prolonged numbness of part of the face. Before any procedure your doctor should explain the risks and benefits to you. Acupuncture, hypnosis, electrical nerve stimulation and psychotherapy are helpful in some people. Your doctor may also order a CT Scan or MRI to find out if you have a blood vessel or tumor pressing on the fifth nerve. If any abnormality is found or if all other treatments have not worked, then gamma knife or open surgery may be necessary to directly relieve the pressure on the nerve as it leaves the brain.