Trigeminal neuralgia is an extremely painful disorder of the cranial nerve of the same name (trigeminal nerve). It causes sudden, intense attacks of pain in the face. It is important to us to inform you on this page about the complexities of this condition – and to show you possible innovative treatment options.
The state-of-the-art, safe and effective CyberKnife method, which we offer at ERCM, achieves lasting pain relief in 70% of cases when correctly indicated – often even complete pain relief.
We accompany you on your journey to a life as pain-free as possible. Arrange your personal initial consultation now at the European Radiosurgery Center Munich.
Trigeminal neuralgia is characterized by severe, sudden, one-sided facial pain. Its causes are still not fully understood [1, 2] . However, one thing is clear: facial pain can severely impair the quality of life of those affected. Individual attacks of pain last for a few seconds, often up to two minutes. This can occur countless times a day – spontaneously, out of the blue.
For many patients with trigeminal neuralgia, everyday activities such as washing their face are often extremely painful. And because the pain episodes persist for extended periods or recur repeatedly, they are often accompanied by significant emotional stress. All of this leads to those affected often withdrawing from their social environment.
The symptoms can also be triggered, for example, by speaking, chewing and swallowing, brushing teeth, or simply touching the area supplied by the trigeminal nerve. This nerve is the fifth cranial nerve, which divides into three main branches: the ophthalmic, maxillary, and mandibular branches. It is primarily responsible for sensations in the face, but also for the chewing muscles, for example.
The good news: There are now a wide range of tailored and innovative treatment options to eliminate the facial pain of trigeminal neuralgia or at least to better control it or reduce its frequency and intensity.
Through the highly precise, robot-guided CyberKnife or ZAP-X therapy, as we perform it here at ERCM, trigeminal neuralgia can be effectively, permanently and safely eliminated in certain cases using this sub-millimeter-precise technology [3].
New scientific research shows that radiosurgical treatment is an effective therapy for a very large number of affected patients [3].
Trigeminal neuralgia is a relatively rare condition that affects approximately 4 out of 100,000 people each year for the first time. The likelihood of experiencing such pain episodes increases with age. Over the years, not only visible changes to our skin can occur, but also changes to our blood vessels and nerves.
The average age of onset is 53 to 57 years. Women are affected more frequently (60%) than men (40%) [2]. A genetic component has also been discussed as a possible cause, with trigeminal neuralgia apparently running more frequently in families [2].
The trigeminal nerve is responsible for informing the brain about sensations in the facial skin. A function that is disrupted in trigeminal neuralgia: The nerve reports intense pain to the brain in a flash, even when the skin is completely intact and uninjured.
Medical guidelines distinguish between different forms of the disease based on their causes [2]. Classic trigeminal neuralgia is described as pathological vascular-nerve contact at the root entry point of the cranial nerve. It sounds complicated, but simply put, it means that a neighboring blood vessel often presses on the trigeminal nerve – most commonly on the mandibular or maxillary branch, i.e., the 2nd or 3rd nerve branch.
In up to 15% of patients, modern imaging can reveal other triggers – this is referred to as secondary or symptomatic trigeminal neuralgia [2]. Other diseases that may be hidden behind the typical symptoms should be considered, especially in younger patients. Commonly encountered conditions include multiple sclerosis (MS), a benign acoustic neuroma (vestibular schwannoma), an AV malformation – usually a congenital vascular malformation in the brain – or other degenerations [4].
Both forms of the disease – both classical and secondary trigeminal neuralgia – can appear with individual attacks of pain, but can also be accompanied by persistent pain [2].
For around a third of trigeminal attacks, it remains a single episode of pain throughout their entire life. However, because facial pain often radiates into the jaw area, it is sometimes misinterpreted as toothache—and consequently treated incorrectly.
Unfortunately, trigeminal neuralgia causes some of the most severe pain of all. Patients suffer considerably from the severe, often spontaneous attacks of pain, which primarily occur in the cheeks, lips, tongue, and chewing muscles. The frequency of individual attacks with electric shock-like pain ranges from hundreds per day [2]. The frequency, duration, and intensity can change over time and even increase significantly. Even normally non-painful stimuli, such as eating, can trigger facial pain.
Most patients are symptom-free between attacks, but some also describe dull, low-threshold, persistent pain [2]. The causes of persistent pain in trigeminal neuralgia are not fully understood [2].
We can't always pinpoint the exact cause. In most cases, however, we find a nearby blood vessel pressing on the trigeminal nerve—in medical terminology, this is called neurovascular compression (NVC). As a result, the nerve in the area of the pressure point loses its protective myelin sheath. Because the nerve is severely damaged in this way, sudden facial pain strikes.
Such neurovascular conflict most commonly occurs in the superior cerebellar artery (SCA) – an artery supplying the cerebellum – in 70 to 80% of cases. Only rarely, for example, can veins exert pressure on the trigeminal nerve or its branches [1].
It is also possible that trigeminal neuralgia is the result of another disease or is hereditary or occurs frequently in families.
Your individual history of facial pain and a thorough clinical examination are crucial for diagnosis [5]. To differentiate between the different forms of the disease, we use modern imaging techniques, particularly magnetic resonance imaging (MRI).
The described compressions can be detected using three-dimensional (3D) time-of-flight magnetic resonance angiography (3D TOF MRA) combined with high-resolution T2-weighted imaging (HR T2WI) – which has a particularly high signal intensity. Recent scientific data demonstrate excellent sensitivity (over 80%) and specificity (100%) for this method – thus playing a key role in deciding which treatment should be used in an individual case [1, 6].
Trigeminal neuralgia must always be distinguished from trigeminal neuropathy. The latter is typically presents with persistent pain, but this is due to direct damage or disease of the nervous system in the jaw and facial area (e.g. trauma or infection). Such painful neuropathies often occur after dental procedures [2]. However, there are also mixed forms of neuralgia and neuropathy.
For the treatment of trigeminal neuralgia, conservative measures with medication or surgical procedures are available for long-term and effective pain relief.
In some cases, pain attacks can be well controlled with medication. Only a few drugs are approved for the treatment of trigeminal neuralgia in Germany [2, 5]. However, potential side effects of drug treatment, such as long-term liver damage, must be considered. Reasons that speak not least for a review of surgical and radiosurgical treatment options with CyberKnife therapy.
Surgical therapies aim to treat facial pain caused by compression by relieving pressure on the trigeminal nerve. The goal is to prevent direct contact between the compressive blood vessel and the nerve. The American neurosurgeon Peter Joseph Jannetta developed a procedure for this purpose, first performed in 1966: the microvascular decompression (MVD), or Jannetta procedure for short. In this procedure, the compressive blood vessel is cushioned by the nerve with a small sponge (Teflon or polytetrafluoroethylene interposition) [1].
The trigeminal nerve itself is not damaged by this surgical procedure, which requires opening the skull behind the ear on the affected side (retrosigmoid approach).
Possible side effects or complications, regardless of the patient's age, include hearing impairment or loss. Sensory disturbances on the affected side of the face may also occur.
After a Jannetta operation, the nerve pain in the face has disappeared in most cases or at least improved significantly (80 to 95%). The long-term results are also good, with approximately 70% pain relief 5 or 10 years after the operation.
If the Jannetta procedure is not possible or the patient does not want it, lasting pain relief or freedom from pain for several years can be achieved through lesional surgery of the Gasserian ganglion. This is the nerve junction where the trigeminal nerve divides into its main branches.
In selective thermocoagulation, for example, pain-conducting fibers are damaged using heat, typically at temperatures around 72 to 75 degrees Celsius. [1]
Other variants include a pressure-mediated ( balloon compression at 1.5 bar) or alcohol-mediated ( glycerol rhizotomy ) partial lesion of the nerve and thus also the destruction of the pain-conducting nerve fibers.
The disadvantage of percutaneous procedures is that they are invasive. The effect may diminish over time, meaning pain attacks may recur later. While percutaneous procedures can be repeated multiple times, the chances of success in these cases are always lower than with the initial procedure [1].
Outpatient radiosurgical treatment with modern robotic systems, such as the CyberKnife and the ZAP-X, is increasingly being used in the treatment of patients with trigeminal neuralgia [7]. Compared to percutaneous, invasive procedures, radiosurgery has the major advantage of being a non-invasive treatment method—therefore, the body surface does not need to be damaged for successful therapy [1].
New findings from various studies demonstrate fewer complications and better long-term relief with radiosurgical treatment. [8] Depending on the individual patient history and cause, trigeminal neuralgia can be treated in a single outpatient session using the high-precision technology of the CyberKnife system. Within a few weeks, scarring of the trigeminal nerve occurs, resulting in pain relief or complete freedom from pain. New scientific data also demonstrate excellent pain control with CyberKnife treatment. [9]
Should a recurrence with pain attacks occur, repeated radiosurgical treatment of trigeminal neuralgia can provide relief: In contrast to invasive methods (e.g., balloon compression), the CyberKnife does not reduce the probability of optimal treatment success with a reduction in the individual disease burden, even if the recurrence is treated [1, 9]. Specifically, even in the event of a recurrence, pain control can be restored with the help of CyberKnife therapy.
The increasing complexity of treatment options means that the decision to undergo therapy should always be made with your individual life situation in mind. It is important to us that you, your family, and those who support and accompany you have a thorough understanding of all aspects of your illness and its treatment options, and are able to make sense of them for yourself.
Our team is committed to ensuring that you feel well cared for from the very beginning here at ERCM. For treatment inquiries, please use the contact form. You can also reach us by phone during our opening hours or via our social media channels.
Your request will be processed individually and promptly.
Yes, trigeminal neuralgia is generally considered a chronic condition. It is a neurological disorder characterized by recurring and acute episodes of facial pain. The pain attacks are often short-lived but very intense and distressing.
Emotional stress can worsen the symptoms of trigeminal neuralgia.
Classic trigeminal neuralgia has no obvious cause, and the pain attacks occur without any identifiable trigger. Often, a nearby blood vessel is pressing on the trigeminal nerve. Symptomatic trigeminal neuralgia occurs as a result of other diseases, including multiple sclerosis (MS), vascular malformations in the brain, inflammation, or injury. The symptoms that occur—sudden, shooting facial pain—correspond to the classic form.
The pain episodes usually do not go away on their own, but can vary in intensity and frequency. Some patients experience periods of improvement, while others continue to suffer from symptoms.
Various neurological medications are used to treat trigeminal neuralgia. Individual medication treatment should always be discussed in detail with your treating neurologist.
Yes, even despite successful treatment, pain attacks can recur. It's possible that if pain recurs, further treatment may be necessary to achieve proper pain control. Studies have shown that radiosurgery is more effective than invasive procedures, where repeat treatments after the initial treatment are less effective.
Approximately 10% of patients may experience numbness in the treated side of the face after radiosurgery with the CyberKnife or ZAP-X. This is due to the fact that the essential nerve fibers of the trigeminal nerve transmit sensation to the brainstem. Typically, this is a mild sensory disturbance, but in very rare cases, complete loss of sensation in the affected side of the face can occur. The motor function of the facial muscles is not affected.
Trigeminal neuralgia and migraine are two different diseases with different cause
[1] Ahmadi, R., Tronnier, V. M., Operative Behandlung der Trigeminusneuralgie. Schmerz 2024.
https://doi.org/10.1007/s00482-024-00835-9
[2] Goßrau, G., Gierthmühlen, J., et al., Diagnose und Therapie der Trigeminusneuralgie, S1-Leitlinie 2023, In: Deutsche Gesellschaft für Neurologie (Hrsg.), Leitlinien für Diagnostik und Therapie in der Neurologie; Online: www.dgn.org/leitlininen (abgerufen am 28.10.2024).
https://www.dgn.org/leitlininen
[3] Régis, J., Tuleasca, C., Resseguier, N., Carron, R., Donnet, A., et al., Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohortstudy. J Neurosurg. 2016:124(4):1079-1087.
https://thejns.org/view/journals/j-neurosurg/124/4/article-p1079.xml
[4] Laakso, S. M., Hekali, O., Kurdo, G., Martola, J., Sairanen, T., Atula, S., Trigeminal neuralgia in multiple sclerosis: Prevalence and association with demyelination. Acta Neurol Scand. 2020;142(2):139-144.
https://onlinelibrary.wiley.com/doi/10.1111/ane.13243
[5] Ruscheweyh, R., Gierthmühlen, J., Hedderich, D. M., Goßrau, G., Leis MME, S., et al., Medikamentöse Therapie der Trigeminusneuralgie. Schmerz 2024;38:283-292.
https://link.springer.com/article/10.1007/s00482-024-00810-4
[6] Liang, C., Yang, L., Zhang, B., Li, R., Guo, S., 3D multimodal image fusion based on MRI in the preoperative evaluation of microvascular decompression: A meta-analysis. Exp Ther Medicine 2023;25:171-178.
https://www.spandidos-publications.com/10.3892/etm.2023.11870
[7] Pollock, B. E., Phuong, L. K., Foote, R. L., Stafford, S. L., Gorman, D. A., High-dose trigeminal radiosurgery associated with increased risk of trigeminal nerve dysfunction. Neurosurgery 2001;49(1):58-62.
https://journals.lww.com/neurosurgery/abstract/2001/07000/high_dose_trigeminal_neuralgia_radiosurgery.8.aspx
[8] Alvarez-Pinzon, A. M., Wolf, A. L., Swedberg, H. N., Barkley, K. A., Cucalon, J., et al., Comparison of Percutaneous Retrogasserian Balloon Compression and Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Multiple Sclerosis. World Neurosurg 2017;97:590-594.
https://www.sciencedirect.com/science/article/abs/pii/S1878875016310166?via%3Dihub
[9] Romanelli, P., Conti, A., Redaelli, I., Martinotti, A. S., Bergantin, A., et al., Cyberknife Radiosurgery for Trigeminal Neuralgia. Cureus. 2019;11(10):e6014.
https://www.cureus.com/articles/23587-cyberknife-radiosurgery-for-trigeminal-neuralgia#!/