Persistent facial pain remains one of the most challenging and complex conditions neurologists and neurosurgeons manage. A man in his 50s described his symptoms as “being tased constantly,” a classic presentation of trigeminal neuralgia. The condition produces sudden, electric shock-like pain triggered by routine activities such as chewing, speaking, or even light touch.
Trigeminal neuralgia may be idiopathic or related to neurovascular compression, and its physical and psychological burden is significant. Historically considered a severe recurrent condition with limited treatment options, trigeminal neuralgia is benefiting from a field that is now evolving to develop more effective interventions.
“In my first two months, the volume of patients has been striking. There’s a significant backlog of people who have lived with severe pain, tried multiple interventions, and had nowhere else to turn,” said Ahmad Alhourani, M.D., Assistant Professor in the Department of Neurological Surgery and the Peter O'Donnell Jr. Brain Institute at UT Southwestern Medical Center.
New Standards for Care
Under Dr. Alhourani’s care, a patient who had suffered for years without answers underwent microvascular decompression (MVD), which involves moving a vessel compressing the trigeminal nerve. The procedure provided immediate relief, enabled him to taper off medications, and minimized treatment-related side effects, and now he has fully returned to routine daily activities.
Despite common perceptions among patients, modern surgical interventions for facial pain often carry lower long-term risk than chronic high-dose pharmacologic therapy. Neuralgia medications can produce cognitive, functional, and systemic side effects that exceed the risks of the surgical procedures that Dr. Alhourani is spearheading at UT Southwestern.
“Most of the time, the surgical risk is less than the side effects from medications,” Dr. Alhourani said. “Ultimately, I want what is optimal for each patient: the least invasive, safest option with the greatest benefit.”
UT Southwestern also offers percutaneous rhizotomy, in which a surgeon uses a small needle to disrupt the pain signal sent out by a specific nerve. While not widely available for treating facial pain at other medical centers, the procedures available at UTSW enable many patients to reduce or discontinue medication use and regain quality of life.
“Our program is also distinguished by the availability of deep brain stimulation (DBS) for facial pain and nucleus caudalis dorsal root entry zone (DREZ) procedures, a technique I refined during residency that targets a different level of pain processing,” Dr. Alhourani said.
These advanced procedures are performed by only a small number of neurosurgeons nationally but have demonstrated meaningful outcomes in patients with refractory facial pain who have exhausted conventional therapies.
“After one intervention, patients can function without living in constant fear of debilitating attacks,” Dr. Alhourani explained.
Early Intervention Is Critical
Refractory facial pain syndrome, including classic trigeminal neuralgia and atypical facial pain, can remain highly debilitating when not addressed early. If pain persists unchecked, the rewiring of the pain circuitry may continue even after the pain is resolved.
“Outcomes are better when pain is treated early – before lasting changes occur in the brain,” Dr. Alhourani said. “Long-term pain doesn’t just hurt physically; it influences psychological processing and shapes how patients view the world.”
Dr. Alhourani’s practice includes both untreated patients and those refractory to medicine as well as prior, unsuccessful operations. Some patients arrive at UT Southwestern because they continue to experience severe pain following rhizotomies performed at other facilities.
A Promising Future
UT Southwestern’s multidisciplinary, team-based approach helps ensure patients are treated with timely and effective interventions aligned with their goals.
“It really takes a village to ensure each patient receives the most effective relief possible and can maximize their quality of life,” Dr. Alhourani said.
The team continues to advance the field and set even higher standards of care through participation in multicenter trials and development of emerging options such as closed-loop neuromodulation and high-frequency ultrasound for facial pain.
“It’s very humbling, because of the complexity and limited options until now – especially for those going through so much,” Dr. Alhourani added. “Yet it is also so rewarding and hopeful when you see patients relieved of pain with significant overall life improvements.”
With experts on the case, living with severe and debilitating facial pain is no longer a life sentence and successful treatment is becoming more accessible. As research continues and care evolves, patients have even more options towards a life without pain.