Chief, Pain Medicine & Palliative Care, Artemis Hospitals, Gurgaon, India
Part 2 of 12 in Advances in Chronic Pain Management
Facial Pain: Trigeminal Neuralgia, Glossopharyngeal Neuralgia and Sphenopalatine Ganglion Block
June 8, 2025
Trigeminal neuralgia produces sharp, shooting, electric-shock-like pain in one of the three divisions of the trigeminal nerve, severe enough that patients cannot eat, speak, wash their face or lie under a ceiling fan. Around 80% of patients respond to medical management with carbamazepine, oxcarbazepine or eslicarbazepine. For those who do not, Dr. Jain's first-line intervention is radiofrequency ablation of the trigeminal ganglion, a day-care procedure that takes about half an hour and achieves results above 95%, ahead of microvascular decompression or gamma knife, both of which cost more and take two to three months to show effect with roughly 85% success. He is explicit that a neurovascular loop on imaging, conventionally treated as a reason to prefer open decompression, is not a contraindication to ablation in his experience; before ablating, he stimulates the electrode and confirms the patient feels it in the same area as their usual pain. One patient he describes had lived with trigeminal neuralgia for 17 years and had attempted suicide twice before being treated; after ablation, he reports the patient had complete pain relief.
Glossopharyngeal neuralgia causes pain in the throat on swallowing, disabling enough that patients stop eating; it is treated with pulsed radiofrequency of the glossopharyngeal nerve under ultrasound or fluoroscopic guidance, with an average 9 to 12 months of pain relief, a technique also used for Eagle syndrome and for pain from tongue and tonsillar bed cancers. Deeper in the skull, the sphenopalatine ganglion in the pterygopalatine fossa is a target for cluster headache that has not responded to medical treatment, for migraine, and for atypical facial pain such as burning tongue syndrome. Dr. Jain describes treating a 27-year-old patient from Oman with severe bilateral burning tongue pain of several years' standing in a single sitting, placing electrodes on both sides of the face and completing the ablation, done before the COVID pandemic, in about an hour; he reports the patient remains well.
This guide is based on a live Jivo Masterclass — Dr. Ashu Kumar Jain taught doctors across Africa on June 8, 2025.
FROM THE LIVE Q&A
Moderator
Can repeated nerve blocks cause nerve damage or other long-term complications?
Dr. Ashu Kumar Jain
No. These interventions are regional and can be repeated without causing nerve damage or nerve injury. Complications are rare given how far the technology and generators have advanced, and in this practice no serious complication has ever occurred with these blocks or ablations. Blocks can be repeated every four to six weeks and radiofrequency ablation every three months.
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Frequently Asked Questions
Which local anaesthetics, steroids and adjuvants do you usually use for different nerve blocks?▼
Ropivacaine for nerve blocks. For spinal procedures, dexamethasone is the primary steroid. For joint injections, Kenacort (triamcinolone).
How do you distinguish between pain caused by dyspepsia and pain caused by angina pectoris?▼
That sits outside pain medicine. It belongs to cardiology and gastroenterology. This practice does not treat visceral pain originating from the heart or lungs and stays restricted to musculoskeletal and neuropathic pain.
Patients often present with pain that has both a surgical solution and a pain-management solution. How do doctors decide when a patient needs surgery versus pain management?▼
Under international Spine Society guidelines, when the primary problem is pain alone, the patient does not need surgery, regardless of the degree of compression shown on imaging, as long as it is below L2. Surgery is indicated for disability: foot drop, motor deficit, sensory deficit, or more than moderate to severe canal stenosis on MRI, where an intervention can only buy time rather than treat the underlying disease. At Artemis, pain medicine and spine surgery work as a team. If a patient referred for pain turns out to have a neurological deficit, they go straight to the spine surgeon; if pain is the only presenting symptom, pain medicine treats it. The line between the two is clear.
Bone marrow transplant cures sickle cell disease but is not offered to every patient, partly for financial reasons. How can sickle cell patients with chronic pain from avascular necrosis of the femoral head benefit?▼
If the femoral head itself is involved, radiofrequency ablation of the hip joint, targeting the genicular nerves supplying the joint, is a very rewarding procedure. But if the pain originates from the bone itself or has a visceral component, high-dose NSAIDs risk the kidneys and the better approach is opioid-based: morphine or tramadol with paracetamol and a neuropathic agent, alongside any specific interventional target that exists.
Can you share more about deep brain stimulation for select cases in pain management?▼
That is not something done from pain medicine. Deep brain stimulation is coming up fast as a field, but at Artemis it sits with the neurosurgery team, not pain medicine. That question is better asked at a neurosurgery masterclass.
Does a neurovascular loop on MRI mean a patient with trigeminal neuralgia needs surgery instead of radiofrequency ablation?▼
No. Dr. Jain treats a neurovascular loop as no contraindication to radiofrequency ablation, contrary to conventional teaching that favours microvascular decompression in these cases.
How is correct electrode position confirmed before ablating the trigeminal ganglion?▼
By stimulating the electrode first and checking that the patient feels it in the same area as their usual pain, before proceeding with radiofrequency ablation.
What is glossopharyngeal neuralgia and how is it treated?▼
Pain in the throat triggered by swallowing, severe enough to stop patients eating. It is treated with pulsed radiofrequency of the glossopharyngeal nerve, giving an average of 9 to 12 months of pain relief.
What is sphenopalatine ganglion block used for?▼
Cluster headache that has not responded to medical management, migraine, and atypical facial pain such as burning tongue syndrome, including bilateral cases treated in a single sitting.
In This Series: Advances in Chronic Pain Management
- 1.Advances in Chronic Pain Management
- 2.Facial Pain: Trigeminal Neuralgia, Glossopharyngeal Neuralgia and Sphenopalatine Ganglion Block
- 3.Cervicogenic Headache and Neck Pain: Cervical Facet Radiofrequency Ablation
- 4.Cervical Radiculopathy: Epidural Injection and Why Cathlab Safety Matters
- 5.Thoracic Facetogenic Pain and T2-T3 Sympathectomy for the Upper Limb
- 6.Shoulder Pain Without Surgery: Adhesive Capsulitis and the Three-in-One Block
- 7.Failed Back Surgery, Sciatica and SI Joint Pain: Transforaminal Adhesiolysis and Facet RFA
- 8.Discogenic Low Back Pain: Biacuplasty and Intradiscal Radiofrequency Ablation
- 9.Cancer, Pelvic and Perineal Pain: Visceral Nerve Blocks and Ganglion Impar
- 10.Knee Pain Without Surgery: Cooled Radiofrequency Ablation and Regenerative Options
- 11.Spinal Cord Stimulation and Intrathecal Pumps for Pain That Doesn't Respond to Anything Else
- 12.Opioids and Sickle Cell Pain: When They Are Habit-Forming and When They Are Not