Another interesting article about trigeminal neuralgia appeared recently — but once again it focuses on the classical form. The one that medicine knows best: attacks of pain like an electric shock, triggered by touch, movement, a gust of wind. It's an important and much-needed article, because this pain can be devastating.
And yet I have the impression that articles about the second form of trigeminal neuralgia — the one with constant pain resulting from nerve damage — are nearly impossible to find. Continuous, unrelenting facial pain — burning, tormenting, present every single day — far less often makes it into the media, and frequently not even into medical offices.
That's why I'm writing about constant pain once again.
I hope that articles like this will become more common and that constant pain in trigeminal neuralgia will be discussed more often and more loudly. That thanks to this, patients will no longer wander between offices for years, undergoing unnecessary dental procedures and having healthy teeth extracted in search of the cause of their pain.
Because in this type of neuralgia, time matters. A quick, accurate diagnosis and early treatment can determine whether pain becomes chronic and debilitating, or whether it can be controlled before it takes over a person's life.
Two faces of trigeminal neuralgia
In common awareness, trigeminal neuralgia almost always means one thing: sudden, brief, electric shock-like pains. This is so-called classical trigeminal neuralgia (TN type I) — it's described in textbooks, covered in articles, and diagnosed relatively reliably.
However, there is a second form — far less often recognized, and for many patients equally or even more devastating: constant neuropathic facial pain resulting from trigeminal nerve damage.
In international classifications — such as ICHD-3 and ICD-11, developed in part by the International Association for the Study of Pain — this condition is known as painful trigeminal neuropathy.
This distinction is not an academic nuance. It determines diagnosis, treatment, and prognosis.
What is painful trigeminal neuropathy?
Painful trigeminal neuropathy is chronic pain in the area innervated by one or more branches of the trigeminal nerve, resulting from nerve damage. The key word here is chronic.
Unlike TN type I:
- Pain does not appear only in paroxysms
- It is continuous or near-continuous
- It is burning, searing, squeezing, numbing in character
- It often lasts most of the day, every day
In some patients, brief, sharper pain episodes may also occur, but it is the constant pain that dominates the clinical picture and determines the patient's suffering.
Why pain becomes constant
The mechanisms underlying this form of neuralgia differ fundamentally from the classic "neurovascular conflict."
What occurs:
- Direct damage to nerve fibers (e.g., from trauma, surgery, infection, demyelination)
- Disrupted impulse conduction and spontaneous discharges in damaged afferent fibers
- Peripheral and central sensitization — the nervous system "learns" pain and sustains it even without an active stimulus
This is precisely why treatments effective for classical neuralgia often fail to produce expected results in patients with neuropathic pain.
What can damage the trigeminal nerve?
The list of potential causes is long — and often surprisingly "everyday":
- Craniofacial trauma
- Dental procedures (extractions, implants, root canal treatment)
- Jaw, sinus, or facial surgery
- Post-traumatic neuropathies from fractures
- Nerve infections (e.g., viral)
- Systemic diseases causing neuropathies
- Structural changes: tumors, inflammatory lesions, demyelination (e.g., in multiple sclerosis)
In some cases, the cause cannot be definitively identified, which does not mean the pain is "psychogenic" — it only means that nerve damage can be difficult to detect.
How patients describe this pain
Patient descriptions are often strikingly similar:
- "As if my face were burned"
- "Constant burning and pressure"
- "Pain that never goes away"
- "Numbness combined with pain"
Frequently co-occurring:
- Sensory disturbances (hypersensitivity, allodynia, paresthesia)
- Areas of reduced sensation
- Worsening of pain with jaw movement, touch, or temperature changes — although classic "trigger points" may be entirely absent
That is why a detailed clinical history is one of the most important diagnostic tools.
Diagnosis: what truly matters
The foundation is a combination of:
- A thorough clinical history (keeping a pain diary is helpful)
- Neurological examination of the face
- Appropriate imaging studies
Most commonly performed:
- MRI of the brain with brainstem assessment, to rule out vascular compression, demyelinating lesions, or tumors
(MRI may not show trigeminal nerve damage — but that does not mean damage isn't present. MRI primarily displays anatomical structures and doesn't always reveal nerve function or micro-damage to nerve fibers. In painful trigeminal neuropathy, changes often occur at the cellular level: small sensory fibers, myelin sheaths, or abnormal electrical activity of the nerve. Such disturbances may be invisible on standard MRI, even when performed on high-field scanners like 3T. MRI works like a very detailed photograph — it excels at detecting tumors, large structural changes, vascular compression, or demyelination foci, but it doesn't "see" pain or register abnormal nerve discharges. That's why a normal MRI result does not rule out neuropathy, and the diagnosis relies primarily on detailed history, neurological examination, and the pain characteristics reported by the patient.)
- CT of the craniofacial area when post-traumatic or bony changes are suspected
This is crucial, because a wrong diagnosis leads to wrong treatment — and the patient enters an endless cycle of ineffective procedures.
Most common diagnostic errors
Constant facial pain is frequently confused with:
- Dental pain
- Sinusitis
- Temporomandibular joint dysfunction
- Tension-type headaches
- Myofascial pain syndromes
- Chronic idiopathic facial pain
The result: extraction of healthy teeth, additional procedures, and mounting patient frustration — before anyone considers neuropathy.
The psychosocial burden of pain
Chronic facial pain is not only a somatic complaint.
It is:
- Social isolation
- Difficulty eating, speaking, working
- High levels of anxiety and depression
- A sense of being misunderstood and being an "incredible patient"
Psychological support, educating loved ones, and connecting with other patients are not extras — they are part of treatment.
Why we need to talk about this more loudly
Because time matters.
The sooner the neuropathic nature of pain is recognized, the greater the chance that:
- The process of chronification can be halted
- Treatment will be targeted
- The patient won't lose years of life to ineffective procedures
Painful trigeminal neuropathy is not a rare curiosity. It is a real, debilitating problem affecting thousands of people — and it deserves to be taken as seriously as its "better-known" classical form.
And you — what type of pain do you live with?
Is it brief, sudden attacks resembling electric shocks, or rather a constant, burning, unrelenting facial pain?
Or perhaps you experience a mixed form, where continuous neuropathic pain alternates with acute paroxysms typical of classical trigeminal neuralgia?
Natalia — since 2014 I've been living with trigeminal nerve pain. I write in plain language, based on reliable sources and personal experience. Read my story →
Frequently Asked Questions
What is trigeminal neuralgia?
Trigeminal neuralgia is a chronic facial pain condition. It manifests as sudden, severe, usually one-sided pain attacks — often described as an electric shock. A single attack typically lasts from a few seconds to about two minutes.
What is the difference between neuralgia and neuropathy?
In simple terms: neuralgia primarily involves paroxysmal pain along a nerve, usually without loss of sensation. Neuropathy involves nerve damage that more often causes constant pain along with numbness and sensory loss.
Do regular painkillers help with neuropathic pain?
Usually not. Neuropathic pain responds poorly to paracetamol or anti-inflammatory drugs. Instead, medications that act on nerves are used, such as anticonvulsants like carbamazepine.
What is neurovascular conflict (vascular compression)?
This is the most common cause of classical trigeminal neuralgia — a blood vessel compresses the nerve root at the base of the brain, damaging its myelin sheath and triggering pain.
Why is an MRI performed?
MRI helps detect neurovascular conflict and rule out other causes of pain, such as tumors or multiple sclerosis. The diagnosis of neuralgia itself is primarily clinical.
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