Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 24-02: Facial Pain + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Brief episodes of stabbing facial pain Pain is in the territory of the second and third division of the trigeminal nerve Pain exacerbated by touch +++ General Considerations ++ Trigeminal neuralgia (tic douloureux) is most common in middle and later life It affects women more frequently than men Pain may be due to an anomalous artery or vein impinging on the trigeminal nerve + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Momentary episodes of sudden lancinating facial pain Commonly arises near one side of the mouth and shoots toward the ipsilateral ear, eye, or nostril The pain may be triggered by touch, movement, drafts, and eating To prevent further attacks, many patients try to hold the face still Symptoms remain confined to the distribution of the trigeminal nerve (usually the second or third division) on one side only Neurologic examination shows no abnormality unless trigeminal neuralgia is symptomatic of some underlying lesion, such as multiple sclerosis or a brainstem neoplasm +++ Differential Diagnosis ++ Atypical facial pain Especially common in middle-aged women Generally a constant burning pain that may have a restricted distribution at onset but soon spreads to the rest of the face on the affected side and sometimes involves the other side of the face, the neck, and the back of the head as well Temporomandibular joint dysfunction Occurs with malocclusion, abnormal bite, or faulty dentures May cause tenderness of the masticatory muscles An association between pain onset and jaw movement Diagnosis requires dental examination and x-rays Giant cell arteritis—may have pain on mastication Sinusitis and ear infections Glaucoma Multiple sclerosis Brainstem tumor Dental caries or abscess Otitis media Glossopharyngeal neuralgia Postherpetic neuralgia + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ Brain MRI Need only be obtained when a secondary cause is suspected Usually normal in classic trigeminal neuralgia +++ Diagnostic Procedures ++ The characteristic features of the pain in trigeminal neuralgia usually distinguish it from other causes of facial pain In a patient younger than 40 years presenting with trigeminal neuralgia, multiple sclerosis must be suspected even if there are no other neurologic signs + Treatment Download Section PDF Listen +++ +++ Medications ++ Carbamazepine (200–600 mg twice daily orally or oxcarbazepine (300–600 mg twice daily orally) is most helpful (monitor blood cell counts and liver biochemical tests) Phenytoin 200–400 mg once daily orally is second choice Baclofen (10–20 mg three or four times daily orally), topiramate (50 mg twice daily orally), or lamotrigine (400 mg daily orally) may be helpful, alone or in combination with carbamazepine or phenytoin Gabapentin Up to 3600 mg daily orally is given in divided doses May relieve pain in patients refractory to conventional therapy and those with multiple sclerosis +++ Surgery ++ Microvascular surgical decompression with separation of the anomalous vessel (usually not visible on CT scans, MRI, or arteriograms) from the nerve root produces long-term relief of symptoms in roughly 75% of patients Three less invasive techniques are based on destruction of nociceptive trigeminal nerve fibers, which will cause sensory loss in addition to symptom relief in half of patients Radiofrequency rhizotomy produces long-term pain relief in 60% of patients Percutaneous balloon compression of the trigeminal ganglion in 67% Stereotactic radiosurgery to the trigeminal nerve root in 45% In elderly patients with a limited life expectancy, radiofrequency rhizotomy and stereotactic radiosurgery are sometimes preferred because both can be performed without general anesthesia and have few complications Surgical exploration is inappropriate in patients with trigeminal neuralgia due to multiple sclerosis + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Spontaneous remissions may occur for several months or longer Progression of the disorder Episodes of pain become more frequent Remissions become shorter and less common A dull ache may persist between the episodes of stabbing pain + Reference Download Section PDF Listen +++ + +Donnet A et al. French guidelines for diagnosis and treatment of classical trigeminal neuralgia (French Headache Society and French Neurosurgical Society). Rev Neurol (Paris). 2017 Mar;173(3):131–51. [PubMed: 28314515]