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Trigeminal neuralgia

Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain. The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur.

The International Headache Society defines trigeminal neuralgia as:

  • a unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve
  • the pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously
  • small areas in the nasolabial fold or chin may be particularly susceptible to the precipitation of pain (trigger areas)
  • the pains usually remit for variable periods

NICE Clinical Knowledge Summaries list the following as red flag symptoms and signs suggesting a serious underlying cause:

  • Sensory changes
  • Deafness or other ear problems
  • History of skin or oral lesions that could spread perineurally
  • Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
  • Optic neuritis
  • A family history of multiple sclerosis
  • Age of onset before 40 years

Management

  • carbamazepine is first-line
  • failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology