Trigeminal Neuralgia

Background

Sudden and severe pain of trigeminal neuralgia as a lightning pain in the face
"tic doloreux" describes the pain that may be triggered by touch or cold
Incidence 5 /100,000, Women > Men, Onset often after 60 years of age
Bouts lasting weeks, remissions lasting months or years
Probably caused by compression of the trigeminal nerve root, close to the pons, by an aberrant arterial or venous loop
1% have involvement of all three nerve branches
About 2% of patients with trigeminal neuralgia have multiple sclerosis

Dental infection or cracked tooth (well localised to tooth, local swelling and erythema)
TMJ pain (often bilateral, may radiate around ear neck, limited jaw opening)
Idiopathic facial pain (often bilateral, outside trigeminal territory, pain continuous & milder.)
Migraine (aura, severe unilateral, assoc GI upset, photophobia)
Temporal arteritis (constant pain, jaw claudication, fever, wt loss, tender non pulsatile temporal arts)

Standard first line treatment is Carbamazepine (NNT 2.6 v placebo) [Evidence Based Neurology]
2nd line: if carbamazepine not effective, antidepressants are useful in neuropathic pain (NNT <5) [Bandolier 2008]
Other drugs including Lamotrigine, Phenytoin, Gabpentin, Oxcarbazine, Topiramate, Baclofen, and Clonazepam
For management of chronic pain please see Neuropathic Pain page in the analgesia section

Microvascular decompression (surgical)
Methods producing a partial trigeminal nerve lesion
Neurectomy, radiofrequency thermal ablation, balloon compression, glycerol injections, and radiosurgery