Facial Pain & Spasms

Causes of Facial Pain

Treatment of Facial Pain

• The most important factor in treatment of this condition is identifying the cause of facial pain. The patient may be seen by their primary care physician and referred to either a neurologist or oral surgeon who can diagnose trigeminal neuralgia. It is important to confirm the cause of facial pain as blood vessel compression of the trigeminal nerve. A variety of tests including MRI of the brain may need to be performed to correctly identify the problem.
• Trigeminal neuralgia caused by blood vessel compression of the nerve as it exits the brain can be treated in a variety of ways.
• Treatment is usually performed by a neurologist who prescribes medications which can help control the abnormal nerve activity resulting in pain. Most patients can be managed with medications alone.
• If medications do not work or cause undesirable side effects, then other treatments are also available. These are usually more invasive and may carry slightly higher risks than treatment with medications alone. These treatments fall into 2 categories, nerve ablation or intentional damage to the abnormal nerve fibers carrying the pain or surgery involving moving the abnormal blood vessels away from the nerve (decompression). Both procedures are administered by a neurosurgeon with other specialists involved as needed.
• Radiosurgery is a technique where high-dose radiation therapy is administered to a section of the trigeminal nerve. This is a technique which intentionally damages the pain fibers and treats the facial pain. This is referred to as gamma knife therapy which is a same-day awake procedure and involves using local anesthetic to numb the scalp so that a circular frame can be attached to the head with small pins. The patient undergoes an MRI and CT scan prior to the procedure and the radiation is given while the patient is awake lying on a special bed that positions the head to receive the x-ray dose. Usually the patient is in the facility for 3-4 hours and the gamma knife treatment lasts about one hour. This treatment usually takes approximately one month before the facial pain starts to decrease. The procedure is about 75% successful after 1 year but then gradually the pain can return. Overall cure rate is about 50-60%. Often, a second radiosurgery can be given for return of facial pain.
• Trigeminal nerve decompression is a surgical procedure performed under general anesthesia. Tiny electrodes are applied to the face and body to allow monitoring of the nerves at the base of the brain during the surgery to increase the safety of the procedure. Next the surgeon makes an incision in the scalp behind the ear and a quarter-sized hole is made in the skull. The surgeon uses a microscope and special instruments to locate the nerve which is being compressed as it exits the brain. Usually a small artery is identified as the cause and is moved away from the nerve and secured using Teflon felt and tissue glue to maintain blood vessel in its new position. Sometimes veins can compress the nerve and are treated by cauterizing the veins and dividing them with tiny scissors. In some cases, the compression can be a combination of artery and vein compressing the nerve. The surgery usually lasts approximately 3-4 hours and a small titanium plate is placed over the hole in the skull and the scalp is closed using absorbable stitches. This procedure involves an overnight stay in the intensive care unit and approximately 3 days in a regular hospital bed. The overall success rate in relieving facial pain is about 80%. The pain relief can be immediate, often within 1-2 days of the surgery. A disadvantage is that surgery is an invasive procedure with a slight risk of hearing loss or facial numbness. Risks of infection and bleeding are also possible.
• Other types of facial pain are treated depending on the cause of the symptoms. Usually a neurologist, dentist, or oral surgeon would be involved with treatment. A neurologist would usually manage MS or post herpes pain. Dental infections or problems with TMJ would be treated by a dentist or oral surgeon.
• Tumors causing compression or invasion of the trigeminal nerve would usually require surgical treatment with removal of the tumor.

Causes of Facial Spasms

• Facial spasm or hemifacial spasm is usually caused by blood vessels compressing the nerve, called the facial nerve, which is responsible for moving the face, as it exits the brain. In this case the nerve conducts abnormal impulses which cause the face to twitch. Usually the entire one half of the face twitches multiple times throughout the day. There is no associated pain or hearing loss. If the spasm occurs while operating a motor vehicle the driver loses outside or peripheral vision which could potentially result in motor vehicle accidents. In addition, the spasms cause a significant change in the patient’s facial appearance which can lead to embarrassment in social situations.
• Tumors along the base of the brain can also compress the facial nerve, though this is an unusual cause.

Treatment of Facial Spasms

• There are 2 common treatments for facial spasm, one involves decreasing the nerve conduction to the muscles of the face and the other is surgical decompression of the facial nerve.
• Usually medications such as Botox (botulinum toxin) can be injected into the facial muscles and decreased facial spasm results. This medication may last from 3-6 months in reducing the facial spasm before it must be repeated. A side effect is facial weakness with droopy appearance of the face. Usually a neurologist administers this medication. Other medications can be given as well to help decrease the abnormal nerve activity. These medications treat the symptoms but do not treat the cause of the facial spasm.
• Surgical treatment involves facial nerve decompression under general anesthesia. Monitoring electrodes are applied monitor the nerves in the region of surgery and the neurosurgeon makes an incision in the scalp behind the ear using a similar approach as with trigeminal nerve decompression. In this surgery the hole made in the skull is located somewhat lower than would be used for trigeminal nerve decompression. The blood vessel compressing the facial nerve is moved away and secured using Teflon felt and tissue glue. The surgery usually takes about 3-4 hours and recovery is like trigeminal nerve decompression. The overall cure rate with surgery is about 85-90%. Risks of surgery are low but can include difficulty swallowing, hearing loss, infection, and bleeding.
• Other rare causes of hemifacial spasm such as tumors compressing the facial nerve would be treated by surgically removing the tumor.