Trigeminal neuralgia

Last updated: July 25, 2023

Summarytoggle arrow icon

Trigeminal neuralgia, or tic douloureux, is a condition characterized by attacks of facial pain in the area of one or more branches of the trigeminal nerve. The pain is typically very severe in intensity, has a sharp, stabbing quality, and lasts for several seconds. Attacks can occur without provocation but are sometimes triggered by innocuous stimuli like chewing. It is a rare condition that typically manifests in patients above the age of 60 years and affects women more often than men. Trigeminal neuralgia is a clinical diagnosis. Neuroimaging (preferably MRI) is used for further classification. Classical trigeminal neuralgia (CTN) is caused by neurovascular compression of the trigeminal nerve root, while secondary trigeminal neuralgia (STN) is caused by an underlying condition (e.g., multiple sclerosis). If there is no identifiable cause, it is referred to as idiopathic trigeminal neuralgia (ITN). Anticonvulsants (especially carbamazepine) are the mainstay of therapy. Surgery may be indicated if pharmacological treatment is insufficient. Options include microvascular decompression (MVD) and transcutaneous procedures that aim to lesion sensory fibers of the trigeminal nerve root or ganglion.

Epidemiologytoggle arrow icon


Epidemiological data refers to the US, unless otherwise specified.

Classificationtoggle arrow icon

Clinical featurestoggle arrow icon

  • 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 occur up to 100 times per day
    • Typically shoots from mouth to the angle of the jaw on the affected side [4]
    • Occurs either at rest or is 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


Diagnosticstoggle arrow icon

Trigeminal neuralgia is a clinical diagnosis. MRI should be performed at least once in the patient's lifetime to evaluate for structural etiology.

Diagnostic criteria

  • All of the following criteria must be fulfilled: [3]
    • Recurring unilateral face pain in the area innervated by one or more divisions of the trigeminal nerve
    • Pain characteristics
      • Severe
      • Lasting no more than two minutes
      • Quality: sharp, shooting, stabbing, or electric shock-like
    • Triggered by innocuous stimuli in the area innervated by the affected trigeminal nerve divisions
    • Another ICHD-3 diagnosis does not better explain the symptoms.


Patients with trigeminal neuralgia and an accompanying neurological deficit require urgent imaging studies (ideally MRI) to rule out a mass or vascular abnormalities. [11]

Additional investigations

  • Electrophysiologic trigeminal reflex measurement [10][12][13]
    • Indication: differentiation of CTN from STN (if MRI is not possible)
    • Procedure: The supraorbital, infraorbital, or mental nerve is stimulated electrically and the response recorded with surface electrodes.
    • Findings

Differential diagnosestoggle arrow icon

References: [11]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon


Inpatient treatment may be necessary for intractable pain in an acute exacerbation. Neurology specialists can adjust antiepileptic medications, provide IV medications, and consider referral for neurosurgical intervention. [12]

Medical therapy [6][12][14][15]

Acute exacerbation

Avoid opioids as they are ineffective for managing pain from trigeminal neuralgia. [12]

Chronic therapy

Surgical therapy [12][14][15]


  • Insufficient response to medical therapy or intolerable side effects [15]
  • Risks and benefits in the individual patient must be carefully weighed.
  • Most procedures have only been investigated in small studies in patients with CTN, and the evidence for their efficacy in patients with STN is even more limited. [12][14]

Microvascular decompression (MVD) [12][14]

  • Indications: Initially established in patients with CTN and signs of neural compression, but may be considered in ITN and STN as well
  • Description
    • Major neurosurgical procedure that requires a high level of expertise
    • Following a suboccipital craniotomy, the blood vessel compressing the trigeminal nerve root is identified and separated from the nerve. A piece of sponge-like material may be placed between the blood vessel and nerve. [17]
    • Achieves the most sustained pain relief in comparison to other invasive treatments [15]
  • Complications include [15]

Percutaneous neuroablative procedures [6][12][15]

  • Description
    • Insertion of a trocar or needle through the foramen ovale to lesion sensory fibers in the trigeminal nerve root
    • Ablation via heat (thermocoagulation), pressure (balloon compression), or chemicals (glycerol injection)
  • Complications include
    • Sensory loss (in up to 50% of patients) [15]
    • Dysesthesia
    • Anesthesia dolorosa
    • Corneal numbness [18]
  • Comparison to MVD
    • Craniotomy is not necessary, resulting in lower periprocedural risk.
    • Lower risk of serious complications
    • Similar rates of initial pain relief (∼ 90%)
    • Lower long-term efficacy (recurrence of pain in around 50% after 5 years) [14]

Gamma knife radiosurgery [12][15]

  • Indications: Consider in patients who cannot undergo open surgery, e.g., due to frailty or those who are anticoagulated.
  • Description: Stereotactic application of high-intensity gamma rays to damage the trigeminal ganglion
    • Pain relief may be delayed (∼ 1 month).
  • Complications include:
    • Sensory loss
    • Paresthesia
    • Recurrence of pain in around 50% of patients 3 years after treatment [15]

Acute management checklisttoggle arrow icon

  • Evaluate for accompanying neurological deficits.
  • Obtain urgent neuroimaging if indicated.
  • Treat acute pain.
  • Initiate anticonvulsant therapy.
  • Refer to an outpatient neurological specialist.
  • Order an outpatient brain MRI if not already obtained.
  • Consider inpatient treatment for intractable pain.

Referencestoggle arrow icon

  1. Shankar Kikkeri N, Nagalli S. Trigeminal Neuralgia. StatPearls. 2021.
  2. Bangash TH. Trigeminal neuralgia: frequency of occurrence in different nerve branches.. Anesthesiology and pain medicine. 2011; 1 (2): p.70-2.doi: 10.5812/kowsar.22287523.2164 . | Open in Read by QxMD
  3. Joanna Baptist, Ajay Nayak, Ravikiran Ongole. Orofacial Pain. In: Ravikiran Ongole, Praveen B N, eds.$Textbook of Oral Medicine, Oral Diagnosis and Oral Radiology E-Book. 3rd, ed. Elsevier Health Sciences; 2021.
  4. Trigeminal Neuralgia. Updated: January 1, 2017. Accessed: April 2, 2017.
  5. Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. 2007; 334 (7586): p.201-205.doi: 10.1136/ . | Open in Read by QxMD
  6. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  7. Bendtsen L, Zakrzewska JM, Abbott J, et al. European Academy of Neurology guideline on trigeminal neuralgia. European Journal of Neurology. 2019; 26 (6): p.831-849.doi: 10.1111/ene.13950 . | Open in Read by QxMD
  8. Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. European Journal of Neurology. 2008; 15 (10): p.1013-1028.doi: 10.1111/j.1468-1331.2008.02185.x . | Open in Read by QxMD
  9. Obermann M. Treatment options in trigeminal neuralgia. Therapeutic Advances in Neurological Disorders. 2010; 3 (2): p.107-115.doi: 10.1177/1756285609359317 . | Open in Read by QxMD
  10. Moore D, Chong MS, Shetty A, Zakrzewska JM. A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia. Br J Anaesth. 2019; 123 (2): p.e385-e396.doi: 10.1016/j.bja.2019.05.026 . | Open in Read by QxMD
  11. Kaufmann AM, Price AV. A history of the Jannetta procedure. J Neurosurg. 2020; 132 (2): p.639-646.doi: 10.3171/2018.10.jns181983 . | Open in Read by QxMD
  12. Asplund P, Blomstedt P, Bergenheim AT. Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia. Neurosurgery. 2015; 78 (3): p.421-428.doi: 10.1227/neu.0000000000001059 . | Open in Read by QxMD
  13. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211.doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  14. 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 (15): p.1183-1190.doi: 10.1212/01.wnl.0000326598.83183.04 . | Open in Read by QxMD
  15. Policeni B et al.. ACR Appropriateness Criteria ® Cranial Neuropathy. J Am Coll Radiol. 2017; 14 (11): p.S406-S420.doi: 10.1016/j.jacr.2017.08.035 . | Open in Read by QxMD
  16. Whitehead MT, Cardenas AM, Corey AS, et al. American College of Radiology ACR Appropriateness Criteria® Headache. J Am Coll Radiol. 2019.doi: 10.1016/j.jacr.2019.05.030 . | Open in Read by QxMD
  17. Cruccu G, Finnerup NB, Jensen TS, et al. Trigeminal neuralgia. Neurology. 2016; 87 (2): p.220-228.doi: 10.1212/wnl.0000000000002840 . | Open in Read by QxMD
  18. Cruccu G, Biasiotta A, Galeotti F, Iannetti GD, Truini A, Gronseth G. Diagnostic accuracy of trigeminal reflex testing in trigeminal neuralgia. Neurology. 2006; 66 (1): p.139-141.doi: 10.1212/01.wnl.0000191388.64530.8f . | Open in Read by QxMD
  19. Trigeminal Neuralgia. Updated: January 1, 2017. Accessed: April 2, 2017.
  20. Trigeminal Neuralgia Fact Sheet. Updated: January 1, 2017. Accessed: April 2, 2017.
  21. Singh MK. Trigeminal Neuralgia: Practice Essentials. Trigeminal Neuralgia: Practice Essentials. New York, NY: WebMD. Updated: November 28, 2016. Accessed: April 2, 2017.

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