Trigeminal neuralgia

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Last reviewed: April 2018

Last updated: November 2017

Summary

Facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve.

Diagnosis is clinical, with a history of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes.

First-line therapy is medical, to which the majority of patients are partially responsive.

Surgical/ablative therapies are reserved for refractory cases.

Ablative therapies can cause facial sensory loss and are associated with a high recurrence rate; however, they are relatively non-invasive and carry minimal risk of severe morbidity/mortality.

Microvascular decompression has few long-term sequelae and well-established efficacy but has a potential risk of major morbidity.

More research on neurostimulation is needed to define its role in the treatment of trigeminal pain.

Definition

Trigeminal neuralgia (TN) is a facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve. It is characterised by some combination of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or a constant component of facial pain, without associated neurological deficit. The pain can be precipitated by trigger areas or factors, and repeat attacks are typically stereotyped in the individual.

History and exam

Key diagnostic factors

facial pain
presence of risk factors

Full details

Other diagnostic factors

prior oropharyngeal or facial trauma
prior herpetic outbreak
sensory/motor changes

Full details

Risk factors

increased age
multiple sclerosis
female
HTN

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Diagnostic investigations

1st investigations to order

no first test

Full details

Investigations to consider

intra-oral x-ray
MRI
trigeminal reflex testing

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Treatment algorithm

ACUTE

refractory trigeminal neuralgia type I/II (TNI/II) (medical and surgical failures); trigeminal neuropathic pain; trigeminal deafferentation pain; symptomatic TN

Contributors

Authors VIEW ALL 

Gaetan Moise, MD

Assistant Professor of Neurological Surgery

Columbia University Medical Center

New York

Disclosures

GM declares that he has no competing interests.

Acknowledgements

Professor Gaetan Moise would like to gratefully acknowledge Professor Christopher J. Winfree, a previous contributor to this monograph. CJW declares that he has no competing interests.

Peer reviewers VIEW ALL 

Alon Y. Mogilner, MD, PhD

Chief

Section of Functional and Restorative Neurosurgery

North Shore-Long Island Jewish Health System

New York

Disclosures

AYM declares that he has no competing interests.

Richard K. Osenbach, MD

Assistant Professor

Division of Neurosurgery

Duke University Medical Center

Durham

Disclosures

RKO declares that he has no competing interests.

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Trigeminal neuralgia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

newly diagnosed trigeminal neuralgia (TN)

anticonvulsant unresponsive trigeminal neuralgia (TN)

medicine-unresponsive trigeminal neuralgia type I (TNI)

medicine-unresponsive trigeminal neuralgia type I/II (TNI/II)

refractory trigeminal neuralgia type I/II (TNI/II) (medical and surgical failures); trigeminal neuropathic pain; trigeminal deafferentation pain; symptomatic TN

Contributors

Authors VIEW ALL 

Gaetan Moise, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Alon Y. Mogilner, MD, PhD

Disclosures

Richard K. Osenbach, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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