The Relationship Between Migraine and Trigeminal Neuralgia

Written by: Kylie Petrarca, RN, BSN

Medically Reviewed by: Dr. Steven Bender

Edited by: Leigh Serth

What is the Trigeminal Nerve?

The trigeminal nerve is the largest of the twelve paired cranial nerves and relays sensations from the face, oral cavity and mucous membranes to the brain. It innervates the face via three branches. The first branch is the ophthalmic branch (V1) which provides sensation to the top and front of the head, eyes, dura mater and frontal sinus. The second branch known as the maxillary branch (V2) provides sensation to the middle of the face such as the cheek, maxillary sinus, top lip, upper teeth and gums. The mandibular branch (V3) is the only branch to have both sensory and motor functions. It primarily innervates the skin of the lower face, lower teeth, tongue, temporomandibular joint and muscles of the jaw.

What is Trigeminal Neuralgia?

Trigeminal Neuralgia (TN) is a neurological condition that affects the trigeminal nerve and causes a severe stabbing, sharp or shock-like pain anywhere from the jaw to the forehead, including inside the mouth.¹ In fact, TN will often mimic pain caused by dental issues. The pain typically presents on one side but can occur bilaterally and more than one branch of the trigeminal nerve can be affected. The pain typically lasts from a second up to two minutes but for some people, the pain lasts 2-10 minutes.² It usually comes without any warning. People can have a few pain attacks per day up to hundreds of attacks per day.² The pain may occur spontaneously but is often triggered by common activities such as chewing, talking, gentle touch and/or pressure to the face, most frequently around the mouth or nose.

Classifications of Trigeminal Neuralgia³

Classical Trigeminal Neuralgia: Caused by compression of the trigeminal nerve by a blood vessel, most commonly an artery. This can lead to atrophy or degeneration of the trigeminal nerve and cause pain.

Secondary Trigeminal Neuralgia: TN that occurs due to an underlying disease such as a tumor or a tangle of arteries and veins known as an arteriovenous malformation.

Idiopathic Trigeminal Neuralgia: Some people have TN where a cause can not be determined. Testing often shows normal results. 

Trigeminal neuralgia is diagnosed after exclusion of other disorders such as cluster headaches, post shingles nerve pain, TMJ disorder and more.⁴ A specialized MRI is needed to rule out a tumor, multiple sclerosis and other causes.

The Connection Between Trigeminal Neuralgia and Migraine

The pathophysiology of both migraine and trigeminal neuralgia involves the trigeminal nerve but it differs in how the nerve is affected. In TN, the pain is usually caused due to compression of the nerve by a blood vessel or tumor. In comparison, electrical activity in the brain (known as cortical spreading depression) is thought to activate the trigeminal nerve in migraine with aura. Although they differ in how they affect the trigeminal nerve, a study found that those who had migraine with aura were at greater risk of developing trigeminal neuralgia.⁵ The link between these conditions is unknown, but it is known that women have a higher prevalence of migraine and trigeminal neuralgia.

Other comorbidities that often coexist with migraine and TN include depression and Sjogren’s syndrome.⁶ It is unknown why these conditions occur together and more research is needed.

Treatment for Trigeminal Neuralgia 

Carbamazepine, an anti-seizure medication, is the only FDA approved treatment for Trigeminal Neuralgia.⁷ TN pain is caused by overactivity of the trigeminal nerve and anti-seizure drugs help slow down the electrical conduction of the brain, nerves and spinal cord. Other medication options include: baclofen, lamotrigine, clonazepam, oxcarbazepine, topiramate, gabapentin, phenytoin, pregabalin, sodium valproate, magnesium infusions and lidocaine infusions.⁶ Antidepressants such as amitriptyline and duloxetine may be prescribed for pain control and help with comorbid depression commonly seen with this condition. Botulinum toxin Type A may also be useful for someone who is delaying surgery.⁶ Interestingly, many of these medications are among the options for preventive treatment of migraine including carbamazepine, some anti-seizure medications, magnesium, certain antidepressants and botulinum toxin A.

Some people find relief using acupuncture where small needles are placed around the body to help decrease pain. Oils such as peppermint and lavender are often used for nerve pain. Meditation has also been found to help decrease chronic pain and stress. 

For people who are unresponsive to medications, microvascular decompression is the preferred surgical treatment. This procedure places a “sponge” between the trigeminal nerve and the compressing blood vessel thereby relieving pressure on the nerve. Additional surgical procedures may include balloon compression, radiosurgery (Gamma Knife®) and radiofrequency lesioning (radiofrequency rhizotomy).⁸

What Type of Doctor is Recommended for Migraine and Narcolepsy?

TN and migraine are typically treated by a neurologist that specializes in headache diseases. For help in finding a neurologist that treats TN, the Facial Pain Association has a list of providers. A neurosurgeon may be involved if TN does not respond to medications. An orofacial pain specialist may also be involved in the diagnosis and management of these disorders. An orofacial pain specialist is a type of doctor that completed dental school plus two years of post-graduate work studying head and facial pain. Board certified specialists can be found at the American Board of Orofacial Pain website (ABOP.net).

A Note To Patients and Providers

Dental work can often be very painful for someone living with Trigeminal Neuralgia. Scheduling regular dentist visits and maintaining good dental hygiene are important and may help lessen pain triggers that can result from dental problems. It is important to discuss your pain with your dental team so that they can adequately prepare for your dental appointments. In some cases your headache and facial pain provider may recommend altering your medication protocol prior to your dental appointments. Maintaining a diary can help track triggers. Providers should be aware of the symptoms of TN in someone who lives with migraine and how to correctly diagnose it. Although this condition is rare, it is most likely underdiagnosed and/or misdiagnosed. Treatment with anti-seizure medications, especially Carbamazepine can be effective for both migraine and TN. More research is needed for TN, therefore those with the condition are encouraged to enroll in clinical trials by routinely checking Antidote or clinicaltrials.gov.

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Resources 

1. Acupuncture for Trigeminal Neuralgia
2. Diagnosis & Treatment of Children with Trigeminal Neuralgia
3. Coping With Trigeminal Neuralgia
4. TIC vs TAC – page 8
5. Podcast – The most painful brain disease you’ve never heard of
6. Find A Doctor
7. Patient Guide on Trigeminal Neuralgia

References

1. https://www.facepain.org/understanding-facial-pain/diagnosis/trigeminal-neuralgia/
2. Bendtsen L, Zakrzewska JM, Heinskou TB, Hodaie M, Leal PRL, Nurmikko T, Obermann M, Cruccu G, Maarbjerg S. Advances in diagnosis, classification, pathophysiology, and management of trigeminal neuralgia. Lancet Neurol. 2020 Sep;19(9):784-796. doi: 10.1016/S1474-4422(20)30233-7. PMID: 32822636.
3. Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A, Eide PK, Leal PRL, Maarbjerg S, May A, Nurmikko T, Obermann M, Jensen TS, Cruccu G. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019 Jun;26(6):831-849. doi: 10.1111/ene.13950. Epub 2019 Apr 8. PMID: 30860637.
4. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Trigeminal-Neuralgia-Fact-Sheet
5. Lin KH, Chen YT, Fuh JL, Wang SJ. Increased risk of trigeminal neuralgia in patients with migraine: A nationwide population-based study. Cephalalgia. 2016 Nov;36(13):1218-1227. doi: 10.1177/0333102415623069. Epub 2016 Jul 19. PMID: 26692399.
6. Yadav YR, Nishtha Y, Sonjjay P, Vijay P, Shailendra R, Yatin K. Trigeminal Neuralgia. Asian J Neurosurg. 2017 Oct-Dec;12(4):585-597. doi: 10.4103/ajns.AJNS_67_14. PMID: 29114270; PMCID: PMC5652082.
7. Gambeta E, Chichorro JG, Zamponi GW. Trigeminal neuralgia: An overview from pathophysiology to pharmacological treatments. Molecular Pain. 2020;16. doi:10.1177/1744806920901890
8. https://neurosurgery.ucsf.edu/trigeminal-neuralgia-faq

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.