History of Trigeminal Neuralgia: From “Tic Douloureux” to Modern Treatment
Trigeminal neuralgia is often described as one of the worst pains known in medicine. It causes sudden electric shock pains in one side of the face, triggered by ordinary actions like brushing your teeth, eating, talking or feeling a cold breeze.
The condition is rare, but not vanishingly rare. Studies suggest around 4 to 13 new cases per 100,000 people each year, with women and older people more often affected. For those who develop it, trigeminal neuralgia can change every part of life: work, relationships, mental health, sleep and the simple act of stepping outside on a windy day.
In this article I set out how doctors have understood and treated trigeminal neuralgia over the last three centuries, and why that history still matters for patients, families and clinicians today.
Long before anyone used the term “trigeminal neuralgia”, medical writers were describing violent pains in the face.
Classical and medieval authors wrote about headaches and facial pains with spasm and distortion of the features. Their language was about humours and “rheums”, not nerves. Some of these descriptions sound like neuralgic pain, but they were mixed in with other conditions such as migraine and facial palsy.
Treatments at that time were based on general theories of imbalance. Patients were bled, purged and cauterised. Herbal mixtures and opium were used to dull pain. There was no concept of the trigeminal nerve or of a specific facial pain syndrome.
Looking back, it is likely that some of these patients did have trigeminal neuralgia, but their experience was buried inside broad, vague labels.
A clear step towards a distinct diagnosis came in eighteenth century Paris.
In 1756, French surgeon Nicolas André published a treatise on convulsive disorders of the face. He described short, stabbing attacks of facial pain with grimacing and twitching. To capture both the pain and the movement, he gave the condition a new name: “tic douloureux”, which translates as “painful tic”.
André believed he was dealing with a convulsive illness rather than a pure pain disorder. He tried to reproduce the pain by pinching nerves with tweezers and attempted treatments with “mercury water” and cautery. These approaches did not stand the test of time, but his terminology did. “Tic douloureux” appears in case reports, textbooks and clinic notes well into the twentieth century.
The next important step in the story came from London.
In 1773, physician John Fothergill presented a paper to the Medical Society of London titled “On a Painful Affection of the Face”. He described 14 patients whose symptoms are instantly recognisable today:
Fothergill was very clear that this condition was different from toothache or migraine. He noted that dental extraction did not cure the pain. His description is so precise that classical trigeminal neuralgia is still sometimes called Fothergill’s disease.
In the nineteenth century, advances in anatomy and physiology changed how doctors thought about facial pain.
Researchers showed that the fifth cranial nerve, now called the trigeminal nerve, carries sensation from the face, mouth and teeth. It has three main branches: ophthalmic (eye and forehead), maxillary (cheek) and mandibular (jaw).
For the first time, the sharp one sided attacks described by André and Fothergill could be mapped onto one or more branches of a specific nerve. Clinicians began to define trigeminal neuralgia as:
By the late nineteenth and early twentieth century, reports were already describing the condition as one of the most severe pains known. Some people took their own lives after years of uncontrolled attacks and failed treatments. This is where a grim nickname emerged in patient stories and some medical texts.
For many years trigeminal neuralgia has been known informally as “the suicide disease”. The phrase arose because the pain can be so severe and so long lasting that some people have felt unable to go on. Modern researchers are cautious about using it, but they do confirm high rates of depression, anxiety and suicidal thoughts in people living with trigeminal neuralgia.
If you are having thoughts of harming yourself or feel you cannot cope, please seek help urgently. In the UK you can contact your GP, call NHS 111, go to A&E in an emergency, or ring Samaritans free on 116 123, 24 hours a day.
Before modern drugs and imaging, treatment was often harsh.
In the late nineteenth and early twentieth centuries, surgeons tried to stop the pain by destroying parts of the trigeminal nerve:
As neurosurgery developed, operations moved inside the skull. Surgeons such as Victor Horsley and later Harvey Cushing and Charles Frazier cut the sensory root of the trigeminal nerve near the Gasserian ganglion inside the skull base.
These operations often reduced or abolished the pain, but they came with serious risks:
At this stage, trigeminal neuralgia was treated almost entirely as a local nerve problem: if you cut or destroy the nerve, you remove the pain. There was no established idea of protecting the nerve by relieving pressure on it.
In the 1920s and 1930s, American neurosurgeon Walter Dandy made an observation that would later change the direction of surgery.
During operations at the back of the skull, he noticed that many patients with trigeminal neuralgia had an artery or vein lying directly across the trigeminal nerve where it enters the brainstem. In a 1932 chapter he suggested that vascular compression of the trigeminal root could be the underlying cause in many cases.
Dandy tried partial sectioning of the trigeminal root and some early decompressive procedures, but his view was limited by the technology of the time. Operating microscopes did not yet exist, and surgical risk remained high. His idea that a blood vessel pressing on the nerve could cause trigeminal neuralgia was ahead of its time and would not be fully proven until the late 1960s.
For much of the early twentieth century, drug treatment was based on experience rather than evidence. Patients were given quinine, arsenic, mercury, bromides, barbiturates and opiates. These sometimes dulled the pain for a while but often caused sedation, toxicity and addiction.
In 1942, a French doctor reported that phenytoin, an anti seizure medicine, reduced trigeminal neuralgia attacks in some patients. This was the first clear sign that anticonvulsants could help by stabilising nerve membranes and reducing abnormal firing.
The major change came in the 1950s and 1960s, when carbamazepine was developed and tested. It was first used in trigeminal neuralgia, where it produced dramatic improvement in many patients, and was then adopted more widely as an anti epileptic drug.
Today, European and UK guidance still recommend carbamazepine or oxcarbazepine as first line long term treatment for classical trigeminal neuralgia. Other medicines, including baclofen, lamotrigine, gabapentin, pregabalin and botulinum toxin injections, are used when first line drugs do not work or cause side effects, but the evidence behind them is less strong.
This means that the basic medicine cabinet for trigeminal neuralgia has changed far less over the last fifty years than many people imagine.
The next major step was driven by new technology rather than a new drug.
In the late 1960s, neurosurgeon Peter Jannetta used the operating microscope to revisit Dandy’s hypothesis. In a 1967 paper he described seeing arteries compressing the trigeminal nerve at the pons in patients with classical trigeminal neuralgia. He then reported excellent pain relief after gently moving the offending vessel away from the nerve and placing a small pad between them.
This operation became known as microvascular decompression (MVD), or the Jannetta procedure. It aims to relieve pressure on the nerve rather than destroy it. The operation is usually carried out through a small opening in the skull behind the ear.
Long term studies show high initial success rates, with many patients becoming pain free and able to stop medication. In modern UK and European guidance, MVD is recommended as the main nerve sparing surgical option for people with classical trigeminal neuralgia who have not responded to medical treatment and are fit enough for an operation.
Alongside microvascular decompression, less invasive percutaneous techniques were developed for people who could not have open brain surgery or preferred a shorter procedure. These treatments are usually done by passing a needle through the cheek into the skull base under X ray guidance.
The main techniques are:
Radiofrequency procedures use a needle and a radiofrequency current to heat the trigeminal ganglion and create a small, controlled lesion. The aim is to interrupt pain carrying fibres while preserving as much normal sensation as possible. Many patients experience rapid pain relief, although some numbness is expected and eye protection must be considered.
Introduced in the early 1980s, glycerol rhizolysis involves injecting glycerol around the trigeminal cistern to damage pain fibres chemically. The procedure is relatively short, can be repeated if needed and is often used in older patients or those with significant other health problems.
Around the same time, Mullan and Lichtor described percutaneous balloon compression of the trigeminal ganglion. A tiny balloon is guided through the foramen ovale and inflated for a short time to compress the ganglion. This selectively injures large myelinated fibres that carry the stabbing paroxysmal pain. Many patients obtain quick relief, again with some degree of altered feeling in the face.
All of these percutaneous procedures are destructive by intention. They are valuable options, especially for older or frail patients, but they do not preserve the nerve in the way that microvascular decompression aims to.
From the 1950s onwards, Swedish neurosurgeon Lars Leksell developed stereotactic radiosurgery, using focused beams of radiation to create small lesions in the brain without opening the skull. Gamma Knife machines, which use multiple cobalt 60 sources, were developed to deliver this treatment precisely.
By the late twentieth century, Gamma Knife and other stereotactic systems were being used to target the trigeminal nerve root entry zone in trigeminal neuralgia. Studies from major centres show that radiosurgery can:
Radiosurgery is now a standard option in many countries, including for people who are not suitable for microvascular decompression or who prefer a non invasive approach.
Current science sees classical trigeminal neuralgia as:
Secondary forms occur when the trigeminal nerve is damaged by other disorders. The most common are multiple sclerosis plaques in the brainstem and tumours compressing the nerve.
High resolution MRI scans can often show a blood vessel in contact with the nerve or rule out secondary causes such as tumours. However, imaging is not perfect. Some people with clear classical symptoms have normal scans. Others without pain may have vascular contact on imaging. Clinical assessment still matters.
For most of its recorded history, trigeminal neuralgia was described almost entirely in terms of anatomy, operations and drugs. Only in the last decade have researchers begun to measure what people with the condition have been saying for years.
Recent studies show that people with trigeminal neuralgia have significantly higher risks of:
than the general population. Newer research has found strong two way links between trigeminal neuralgia and mental disorders such as depression, anxiety and insomnia, with each increasing the risk of the other. Dedicated studies on suicidal thoughts and self harm have reported worrying rates of both, especially in people with more intense pain and greater emotional distress.
Qualitative work on the journey to diagnosis has revealed long delays, repeated misdiagnosis (particularly in dentistry and primary care), and patients being told that the pain is stress, anxiety or “in their head”. When I speak to people with trigeminal neuralgia through my work, they often describe not only the physical agony but the deep isolation of not being believed.
The damage comes not only from the attacks themselves, but also from lost work, strained relationships, fear of triggering pain and years of feeling dismissed or invisible.
Looking back over three centuries, several themes stand out.
For people living with trigeminal neuralgia today, knowing this history is not just academic. It explains why diagnosis is often delayed, why certain operations exist, why some people carry scars and numbness from earlier eras, and why future research must focus not only on nerves and blood vessels, but also on mental health, quality of life and support.
About the author
Aneeta Prem MBE is a UK based campaigner on trigeminal neuralgia, facial pain and human rights. She is the CEO of the Trigeminal Neuralgia Association UK and founded Freedom Charity, which protects children and young people from forced marriage, FGM and what she terms “dishonour abuse”.
For help and support with TN please go to www.tna.org.uk or call 08009991899 option 1 .
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