Ep. 92 | Trigger Point

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In the summer of 2016, a 66-year-old college professor lay down on an examination table in excruciating pain.

It felt like somebody was stabbing his left cheek with an ice pick.

The pain was so bad, his eyes welled up with tears until his vision went blurry.

He could barely see his doctor, who stood across the room filling a syringe with anesthetic.

When the doctor made her way over to the professor, he tensed up.

Over the past few months, he'd had this procedure over and over again, and every second of it was pure agony.

The doctor plunged the needle into his cheek, and immediately the muscles pinched with pain.

The professor dug his nails into the exam table as the doctor withdrew the needle slightly as she looked for her target, target and then plunged it back in again.

Finally, the needle hit a taut mess of nerves that was the source of the professor's pain.

Pain erupted in his cheek and he nearly screamed out.

But at least now the doctor could begin administering the anesthetic.

The medicine burned as it pulled beneath his skin, but then his cheek began to numb, and for the first time in two weeks, the stabbing pain subsided.

The professor was relieved, but he knew this was short-lived.

Soon, the pain would come back, and he would need this horrible procedure again, over and over for the rest of his life.

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From Ballin Studios and Wondery, I'm Mr.

Ballin, and this is Mr.

Ballin's Medical Mysteries, where every week we will explore a new, baffling mystery originating from the one place we all can't escape, our own bodies.

So if you like today's story, please go to the Follow Buttons garage sale and offer to buy their most expensive item, but pay for it entirely in pennies.

This episode is called Trigger Point.

In December of 2015, 65-year-old professor David Linick was meditating in his seat as his plane landed at Philadelphia International Airport.

David was an economics professor at a university in Los Angeles, and he also ran a meditation group on campus.

Meditation kept David grounded, especially during long and noisy flights like this one from LA to Philly.

David took another cleansing breath as the plane rolled toward the gate.

A few minutes later, he stood up to grab his luggage from the overhead compartment.

And as he did, a sharp pain pierced his cheek, just to the left of his nose.

David flinched and instinctively reached up and began massaging the pain point, which helped a little bit.

He moved down the aisle toward the exit door, still rubbing his cheek, and slowly the pain dissipated.

David had never experienced a muscle spasm like that, but he chalked it up to exhaustion and headed for the baggage claim.

Three months later, in March, David tapped his fingers on the exam table at his doctor's office.

He was feeling nervous.

Since his trip to Philadelphia, he'd experienced a few more painful spasms in his cheek.

But over the last week, those sharp bursts of pain had become a daily occurrence.

He was worried they could be related to his history with brain surgery.

Almost 20 years earlier, David was diagnosed with pituitary adenoma, a small benign tumor located on his pituitary gland, which is just behind the nose.

And so he had to undergo brain surgery and also radiation treatments to remove the tumor.

But he'd been free of symptoms ever since.

However, now he was worried that the tumor might be back, or that something related to the surgery might be causing this new pain.

So he'd come in for an MRI and other tests.

A few moments later, his doctor walked into the room.

He had good news.

David's tumor was not back.

In fact, the doctor couldn't find anything physically wrong with him at all.

He asked if David was under more stress than usual.

It was possible that the pain could actually be psychological.

That didn't mean the pain was imaginary, just that it might stem from a combination of factors.

But that did not sound plausible to David.

He was an avid meditator, which gave him an excellent coping mechanism for stress.

Besides, nothing was really weighing on him.

He had actually been enjoying himself over the past few months, except for these new cheek spasms.

He told the doctor as much and then said he wanted a second opinion.

The doctor nodded and said he had an idea.

He recommended that David go see an ear, nose, and throat specialist, or or ENT, and he promised he would send in the referral right away.

Two weeks later, David walked out of that ENT's office feeling frustrated.

The ENT had ordered more scans of David's head and had found that he had a deviated septum, which meant the cartilage that divided David's nostrils was off-center.

But the ENT didn't think a deviated septum would cause this stabbing pain in David's cheek.

And like David's other doctor, the ENT also concluded that the pain might be psychological.

And then he proceeded to ask David if he was under extra stress at work.

Nothing David said could convince the ENT otherwise.

So eventually David gave up.

He would just have to find a different way of dealing with these spasms.

Another few weeks later, David paced at the front of a lecture hall, flicking through a PowerPoint presentation.

And he had just arrived on the final slide when the pain in his cheek returned.

And it returned like an explosion, sending sharp bolts of pain across his whole face.

He winced so hard he nearly dropped the clicker in his hand, but then tried his best to recover.

He didn't want his students to know that anything was wrong here, but at the same time, it felt like the muscles beneath his skin were literally on fire.

He took a deep breath and tried to use his meditating skills and put mind over matter here and get through the presentation, but he couldn't.

The pain was so intense, he had to end the lecture early.

Back in his office, David rushed over to his desk, opened up his lunchbox, and fished out the ice pack he'd brought to keep his food fresh.

Then he placed it on his face, hoping it would take the edge off his pain.

At that moment, he knew for sure that so far, his doctors had been wrong.

This was not a psychological problem.

Something was physically wrong here.

He just needed to find the right doctor who could prove that.

Ten minutes later, David's cheek was still throbbing despite this ice pack.

So he put the ice pack away and then stepped into the hallway to call his dentist.

He figured, you know, maybe if the problem wasn't in his ears, nose, or throat, maybe it was in his teeth.

About a month later, David sat in a reclining dental chair, trying his best to breathe calmly as an oral pain specialist shot streams of cold water directly into the painful side of his mouth.

David had gone to see his dentist, who then referred him to this specialist.

But this specialist didn't find anything physically wrong with David's teeth.

So he proposed an unusual way to help David cope with what appeared to be a psychological problem.

He wanted to train David's mind to simply ignore the shooting pain in his left cheek.

And so the specialist told David to open and close his mouth while he, the specialist, shot streams of cold water at David's gums.

David opened his mouth and tried hard not to flinch as the specialist did this, but each burst of water felt like he had touched a live wire.

David tried to ignore the pain, but by the time the specialist finally put down the water scaler and handed him a paper towel, his whole jaw was throbbing.

The specialist slid his stool back from the dental chair and then told David to mimic this exercise at home, and eventually he would get results.

In the meantime, he was going to prescribe David an antidepressant that's also sometimes used to treat facial pain.

David was not optimistic here.

He felt like he had just undergone a round of torture for nothing.

But he would try the medication and try the exercise and see if maybe this specialist was right.

But a month later, in the summer of 2016, David was meeting with a new oral pain specialist named Dr.

Parker.

For weeks now, he'd been trying the cold water exercise and the antidepressants, but the jolting pain had only gotten worse.

And so he hoped Dr.

Parker could finally figure out what was going on here.

When Dr.

Parker finished up her physical exam of David, she proposed an idea.

She thought they should maybe try direct injections to the area that was triggering the pain.

She would inject local anesthetic directly into his cheek, into a taut band of skeletal muscle, and maybe get the muscles to relax for a while.

She said that should give David some relief.

David thought this sounded like a wonderful idea, and he was game to try it.

So, Dr.

Parker readied the anesthetic, then injected it directly into his cheek.

The pain of getting this injection was shocking, but David was pretty used to shocking pain by now, so he just gritted his teeth and held still.

Once Dr.

Parker was done and had removed the needle, at first David's cheek was just pulsing with pain.

But slowly, the pain subsided, and for the first time in months, he just felt normal again.

He'd never been so grateful for a moment without pain.

Dr.

Parker smiled and told David to come back and see her in two weeks for another injection.

He would need them indefinitely to manage the spasms.

David hated the thought of undergoing that treatment twice a month for the foreseeable future.

But until doctors could find the root cause of his pain, it was his only course of treatment that actually worked.

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In January of 2009, David flipped through a magazine in the waiting room at a new medical office.

After almost three years of finding partial relief through those trigger point injections to his cheek, he had decided to seek help from a new doctor, a neurologist.

The injections were still helpful, but they weren't working as well as they did at first.

The constant, awful pain in his cheek was back.

It was bad during the day, but it got worse when he lay down at night.

It made sleeping miserable, leaving David tired all the time.

Plus, his insurance only covered part of the injections.

At the end of 2018, when he sat down to review his spending for the year, he was shocked by how much he had paid out of pocket for his injections.

And so that motivated him to start searching for answers again, because those injections were just band-aids.

He needed to find the root cause and fix that.

Since the spasms had begun back in 2015, three different specialists had told him that the problem was psychological.

David wanted to believe them, but he had never been convinced.

So he decided to see a neurologist, a doctor who specializes in disorders of the brain.

He figured maybe it was a physical problem with his brain, not a mental one.

Just then, a nurse called his name and he followed her back to a sterile, beige-colored room where he sat down on the exam table.

Soon after that, a young neurologist knocked on the door and introduced herself as Dr.

Bashar.

She asked David to walk her through his symptoms.

David told her the whole story, about the constant stabbing feeling in his cheek, and the limited success he'd had with trigger point injections.

Dr.

Bashar listened as she began a thorough examination of his face, paying extra attention to the painful spot just to the left of his nose.

And when she was done with the exam, she told David that she actually had a whole new diagnosis for him.

In her opinion, David had a condition called trigeminal neuralgia, or TN.

David had never heard of it.

She explained that TN is caused by damage to the trigeminal nerve.

which is responsible for carrying sensations like pain from the face to the brain.

TN can be triggered by a variety of things, a blood vessel pressing on the nerve, an injury from a sinus surgery or dental work, and in some cases, an unknown cause.

But unfortunately, the result is the same.

TN is one of the most painful conditions known to medicine.

It's called a suicide disease because in the years before doctors were able to help patients manage the pain, The pain used to get so intense that some patients would choose to end their own lives rather than deal with the horrible disease.

David thought back to how severe his pain had gotten before the trigger point injections he was getting.

He couldn't imagine living with that pain for years on end.

Dr.

Bashar said she needed more information about his condition before she would know how to help him.

There was yet another specialist she wanted him to go see.

So, a few weeks after his appointment with Dr.

Bashar, David was at another neurologist's office sitting beside a metal cart filled with what looked like computer equipment.

It was an electromyography machine, or EMG, that would measure the function of David's face muscles.

The neurologist taped numerous electrodes to David's face and then turned on the EMG.

Almost immediately, David felt a whole bunch of sharp little electric pulses pricking his skin.

But this pain was nothing compared to the face pain he had been experiencing for the last four years, so he didn't mind.

The machine clicked and pulsed for nearly an hour, and by the end of it, David barely noticed the electric pinpricks.

When the EMG finally turned off, David's neurologist removed the electrodes from his face and moved to the EMG monitor to look over the results.

He told David there was some good news.

His TN was not being caused by a neuromuscular disorder like multiple sclerosis.

Unfortunately though, the EMG did not reveal what was causing it either.

David just sighed.

After four years of disappointing news from specialist after after specialist, he had become hopeful after finally getting properly diagnosed that he had TN.

And he was now hopeful that this EMG would finally uncover a proper treatment for his pain.

But clearly it had not.

And so he asked the neurologist if there was anything else he could do.

The neurologist paused and then said that typically in this situation, he would opt for brain surgery.

to help treat David's pain and fix the damaged nerve.

But given that David had already had brain surgery to remove the pituitary tumor back in 1997, the neurologist did not feel comfortable recommending another brain surgery.

To him, brain surgery should be a true last resort.

First, he wanted David to try managing the pain with painkillers.

He told him to literally try everyone on the market.

Two years later, in the winter of 2021, David was once again sitting in a dentist's chair, but this time for a routine procedure, a crown replacement.

He tried to hold still as his dentist pushed a syringe of novocaine into his gums, but the needle was triggering his TN and making the numbing process overwhelmingly painful.

For the past two years, David had been dutifully working his way through a laundry list of painkillers.

But instead of getting better, David's pain remained basically constant.

In fact, the spasms were so unrelenting that most days he couldn't think straight.

He couldn't even meditate anymore, something that had been a daily practice and comfort to him for years.

He was frustrated and exhausted with the whole ordeal and perfectly understood now why TN used to be called the suicide disease.

Thankfully, the novocaine his dentist had given him did eventually set in and the pain in his cheek finally dulled.

It was the first time in a while that there hadn't been pain in his cheek.

And so even as his dentist began drilling away at the crown on his back tooth, David simply sat there and enjoyed the temporary relief.

But that afternoon, when the Novocaine wore off, the pain came back with a vengeance.

He grabbed an ice pack out of the freezer and pressed it to his cheek, hoping it would numb the pain.

And it did, a little bit, so that night he literally slept on the ice pack.

But it just was not enough.

The throbbing pain in his cheek continued.

David felt like he was going crazy.

He knew that there had to be a proper treatment out there somewhere.

A doctor who could figure out what was actually causing his TN and help him fix it.

So once again, David started Googling, looking for new specialists to call.

A few months later, in June of 2021, David had just wrapped up a lecture when his phone buzzed in his pocket.

It was his newest doctor's office.

David had been waiting for this call for weeks.

After his most recent horrible experience at the dentist, He had made yet another appointment with another neurologist.

And after this neurologist thoroughly examined him, they told David something startling.

In her opinion, David did not have TN at all.

The pain from TN is typically triggered by eating, talking, or brushing your teeth.

But none of those activities seemed to trigger David's pain.

His pain was a constant presence, regardless of what David was doing.

And so this neurologist had ordered an MRI and CT scan to confirm her suspicion.

And so now, David hoped that on this phone call, he would be given finally a proper diagnosis and treatment plan.

David crossed his fingers and answered the call.

The neurologist said that after looking over his MRI, she found no abnormality involving his trigeminal nerve.

That meant that the earlier diagnosis was incorrect and David did not have TN.

Instead, his CT scan showed that he might have a blockage in a sinus passage located at the back of his nose.

She suggested that David's previous doctors had all been looking in the wrong place.

She told him to go see another ear, nose, and throat doctor because if she was right, the answer to David's pain could be a relatively easy fix.

David couldn't believe it.

After all this time, it seemed too good to be true.

And so he promised the neurologist he would contact another ENT right away.

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Almost two years later, in May of 2023, a neurosurgeon named Dr.

Sarah Howard stuffed down a quick lunch while reviewing the medical chart for her next patient.

She was the director of neurosurgical oncology at a healthcare facility in Santa Barbara, California.

And today she was meeting with David, who had recently retired and moved to the beachside town.

Dr.

Howard threw her brown lunch bag into the trash, grabbed her tablet, and hurried down the hallway to the exam room where David was waiting.

From the moment she entered the room, she could tell that David was on edge.

But given how many specialists he had seen over the years, she understood why.

David explained that the last doctor he saw was a neurologist back in 2021.

That doctor sent him to another ear, nose, and throat specialist to look for a blockage in his sinuses.

But the ENT had not found anything wrong.

So David felt like he was back to square one after seven years of looking for answers.

Feeling defeated and depressed, David had stopped hoping for a diagnosis at that point.

and he had suffered excruciating pain ever since.

It had been seven years since the stabbing pain had started.

He just needed it to stop.

Dr.

Howard brought up the MRI image of David's head that had been taken back in 2021.

This was the MRI that supposedly showed he had a sinus blockage rather than TN.

She flipped her tablet around so that David could see the image, and then on the image, she pointed at a small spot on his cheek.

And while he looked, She told him that she knew exactly how to help him.

David looked shocked, but he also tensed up because to this point, nobody seemed to know how to help him.

But Dr.

Howard seemed very confident, and she told him that the solution was brain surgery.

However, because of his complicated medical history, the procedure would be extremely risky and with no guarantees.

In fact, she told him there was a 70% chance the surgery would not relieve his pain at all.

In fact, it might even make the spasms worse.

The last thing Dr.

Howard wanted was for David to have unrealistic hopes here and to undergo a risky procedure only to wind up suffering even more than he was now.

But Dr.

Howard said, look, this is your best chance of relief, but ultimately, the choice is up to you.

Dr.

Howard waited while David tapped his fingers nervously on his knees, thinking it over.

Finally, he asked her to show him the MRI one more time.

She handed him the tablet and let him enlarge the scan, looking at that little spot she had pointed out on his cheek.

Finally, after staring at the image for several moments, David said he had made up his mind.

He was willing to take the risk.

It's unclear why David's previous doctor didn't see it on the 2021 MRI scan.

But the small spot on David's cheek that Dr.

Howard pointed out was a group of blood vessels compressing his left trigeminal nerve.

Although she wasn't sure if surgery could correct the condition, The image made her absolutely certain that David did, in fact, have a case of trigeminal neuralgia or suicide disease, TN.

So in that sense, David's earlier doctors had been right.

But unlike any of his doctors up to that point, Dr.

Howard actually knew how to fix it.

In June of 2023, Dr.

Howard performed that very risky brain surgery.

It's known as a microvascular decompression, and she performed it on the left side of David's head.

She drilled a small hole through his skull behind his left ear.

to expose the trigeminal nerve.

Then she slowly lifted away the blood vessels that were pressing on the nerve and stuck a nearly microscopic Teflon pad between the blood vessels and the nerve.

That way, the blood vessels could not compress the nerve any longer, and that would theoretically alleviate David's pain.

But unfortunately, during the surgery, Dr.

Howard hit a snag.

She found that some small veins had become entangled with David's trigeminal nerve, making it difficult to completely relieve the pressure.

That complication made her worry about how David would feel in the future.

Following the surgery, the pain in David's face did diminish, however, it did not go away completely.

He also felt intermittent compression behind his ear, which Dr.

Howard explained was likely due to nerve scarring, since it had been so many years since the first cheek spasm that was likely caused by these veins.

Dr.

Howard warned David that that compression feeling might end up being permanent.

But David finally found his way back to a sense of normalcy, though he wishes he had done more of his own research when the spasms first started happening.

He thinks that maybe he would have ended up in a neurosurgeon's office much sooner, saving himself a lot of time, money, and pain.

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From Ballin Studios and Wondry, this is Mr.

Ballin's Medical Mysteries, hosted by me, Mr.

Ballin.

A quick note about our stories.

They're all inspired by true events, but we sometimes use pseudonyms to protect the people involved, and some details are fictionalized for dramatic purposes.

And a reminder, the content in this episode is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

This episode was written by Aaron Lam.

Our editor is Heather Dundas.

Sound design is by Ryan Potesta.

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And our coordinating producer is Sarah Mathis.

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