FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Headache & facial pain

Trigeminal neuralgia

CN V neuralgia — usually neurovascular compression of the root

Overview

Sudden, severe, brief, electric-shock-like facial pain in the trigeminal distribution, usually from vascular compression of the nerve root. Paroxysms are triggered by light touch (washing, shaving, chewing). Carbamazepine is first-line.

Recognise

  • Brief (seconds), severe, stabbing/electric-shock pain in one or more trigeminal divisions (usually V2/V3)
  • Triggered by light touch, chewing, cold, brushing teeth, a breeze on the face
  • Refractory periods between attacks; unilateral

Red flags

  • Young patient, bilateral, sensory loss, or other neurology → suspect MS or a structural lesion (atypical features) → MRI

Differentials & how to tell them apart

Cluster headachelonger (15min–2h) periorbital pain with autonomic features, restless
Dental/sinus pathologylocalised, examination/imaging of teeth/sinuses
Multiple sclerosisyounger, bilateral or with other neurology — MRI for demyelination
Postherpetic neuralgiapreceding shingles rash in the dermatome

Investigations

Clinical. MRI to exclude secondary causes (MS plaque, tumour, vascular loop) — especially if atypical or young.

Management

Carbamazepine first-line; refer to neurology/neurosurgery if refractory

  1. 1Carbamazepine first-line, titrated to effect.Gate: Atypical features (age <40, bilateral, sensory loss, other neurology) → MRI to exclude MS or a structural lesion before settling on idiopathic trigeminal neuralgia
  2. 2No response/intolerance → oxcarbazepine, lamotrigine or baclofen; refractory → neurology/neurosurgery (microvascular decompression).
Carbamazepine — first-line (enzyme inducer; monitor for SJS, hyponatraemia, blood dyscrasias)
Oxcarbazepine / lamotrigine / baclofen — alternatives if intolerant

Key points

Touch-triggered electric-shock paroxysms = trigeminal neuralgia; carbamazepine is the answer. New trigeminal neuralgia in a young person suggests MS.

Monitor & prognosis

Pain control, carbamazepine levels/side effects (Na+, FBC, rash).

Often controlled medically; surgery for refractory cases.

Source: NICE CKS Trigeminal neuralgia