Trigeminal Neuralgia

Key Points

  • Trigeminal Neuralgia (TN) is a facial pain disorder
  • Pain is brief, sharp and severe
  • Pain can often be triggered by brushing teeth, talking, shaving or wind exposure
  • Antiepileptics are used for medical management

Introduction

Trigeminal neuralgia is a common facial pain disorder. The annual incidence of TN is four to 12 per 100,000. TN most often occurs above age 50, although it can happen at younger ages and in children. Females are affected slightly more than males. TN is also known as tic douloureux.

TN is often caused by trigeminal nerve compression from abnormal vessels, which may lead to damage of the sheath outside the nerve. This may sometimes lead to hyperactive signals from the nerve. Sometimes, compression can be caused by tumor or vascular malformations. Multiple Sclerosis can also present as TN.

Symptoms

  • TN involves pain on one side of the face that is innervated by branches of the trigeminal nerve.
  • The pain is brief and sharp in nature, and most commonly occurs in the cheek or jaw.
  • The pain is reported as an “electric shock” like sensation, lasting seconds.
  • Rarely, pain can occur on both sides.
  • During severe attacks, there can be associated twitching, tightening or spasm of the facial muscles.

TN attacks can be provoked by touching the face, talking, chewing, or brushing teeth. There is often no pain in between the attacks, but some patients with TN complain of continuous dull pain in between TN attacks.

TN attacks can be debilitating and can last for weeks or months followed by pain free intervals.

Differential Diagnosis

Patients with TN could be misdiagnosed as temporomandibular joint (TMJ) disorder. Unlike TMJ, attacks of TN are often brief and sharp and can occur without any jaw movement. There is often no jaw popping sensation, which often occurs with TMJ. Other common differentials include short lasting unilateral neuralgiform (resembling neuralgia or that of neuralgia) headaches with conjunctival injection (forcing of fluid into the conjuctiva, the mucous membrane that lines the eyelids) and tearing (SUNCT) and cluster headaches. These two disorders, SUNCT and cluster headaches, are usually associated with eye tearing, eye redness, droopy eyelid, nasal congestion, and a runny nose. These symptoms would occur on the same side as the pain.

Diagnosis

TN diagnosis is based on the description of symptoms and examination. TN patients often have normal neurological exam. If there are bilateral TN symptoms, numbness in the trigeminal nerve distribution, or younger age of onset, then further evaluation may be needed.

Patients often undergo a brain MRI with contrast to rule out a structural cause of TN. Other specialized imaging may be considered based upon the history and presentation.

Treatment

Anticonvulsants, such as carbamazepine (Tegretol), are often used to treat TN. Other medications such as oxcarbazepine, gabapentin, lamotrigine, baclofen and clonazepam may be considered during the course of TN.

Patients who respond poorly to medical management may be candidates for surgical interventions such as microvascular decompression, rhizotomy or cutting of the nerve, or gamma knife procedures.

References:

  • suHeadache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 2013; 33(9): 629–808
  • Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain 2001; 124: 2347-60.
  • Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ 2007; 334:201-5
  • Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008; 71:1183

© Priyanka Chaudhry, MD; 2014. All rights reserved.
Instructor, Headache Medicine, University of Texas Southwestern Medical Center, on behalf of the New Investigator and Trainee Section of the American Headache Society

This article is a legacy contribution from the American Headache Society Committee for Headache Education (ACHE) and the Fred Sheftell, MD Education Center.

Last updated May 3, 2014