- Clinical science
Trigeminal neuralgia (formerly tic douloureux) is a condition affecting the trigeminal nerve that is characterized by excruciating shooting or stabbing facial pain followed by a burning ache. It is caused by either neurovascular compression from a neighboring vessel (the classical form) or nerve damage resulting from an underlying condition (the painful form), such as multiple sclerosis. Women and older patients are primarily affected, with the peak incidence between 60–70 years of age. Affected individuals experience episodes of facial pain lasting several seconds and occurring up to one hundred times per day. Attacks may happen at rest, but are often triggered by light touch or movements like chewing. Episodes can last from days to years before remitting, but typically reoccur. The excruciating, persistent pain often leads to psychological distress, ranging from dysphoria to severe depression with suicidal tendencies. Diagnosis is based on the patient's medical history and clinical manifestations. Trigeminal neuralgia is managed conservatively with carbamazepine as the drug of choice. Surgery is indicated if medical treatment is not sufficiently effective.
- Sex: ♀ > ♂ (2:1)
- Peak incidence: 60–70 years
Epidemiological data refers to the US, unless otherwise specified.
- Classical trigeminal neuralgia: caused by neurovascular compression, generally by an aberrant loop of a neighboring artery or vein (usually the superior cerebellar artery)
- Painful trigeminal neuropathy: Multiple etiologies are possible. The condition may be caused by underlying disease (e.g., multiple sclerosis), structural lesions (e.g., tumor, cyst, aneurysms), or ischemia in the trigeminal nerve.
Unilateral facial pain: paroxysmal, severe shooting or stabbing (like an electric shock), followed by a burning ache
- Lasts several seconds (in rare cases, several minutes) and may appear up to 100 times per day
- Typically shoots from mouth to the angle of the jaw on the affected side in most cases
- Occurs either at rest or triggered by movements such as chewing, talking or touch (e.g., brushing teeth, washing face); becomes worse with stimulation
- Facial spasms may occur
- Psychological distress: ranging from dysphoria to severe depression with suicidal tendencies
- Usually progressive course
- Clinical diagnosis
- If symptomatic trigeminal neuralgia is suspected, possible underlying conditions should be investigated (esp. via head MRI).
Consider multiple sclerosis in a young female patient with bilateral trigeminal neuralgia!
Trigeminal neuralgia is usually managed conservatively. Surgery is indicated if conservative treatment is not sufficiently effective. In cases of symptomatic trigeminal neuralgia, treatment of the underlying condition should be considered. Subsequent coexisting conditions (e.g., ) should be managed as appropriate.
- Drug of choice:
- Consult neurology.
- MRI of the brain (if not yet performed) 
- Start pharmacologic therapy. 
- Consider in-hospital treatment for severe acute pain exacerbations and/or psychiatric comorbidities (e.g., thoughts of suicide).