QUICK RECERTIFICATION SERIES
Trigeminal neuralgia
Lindsay Gietzen, MS, PA-C
GENERAL FEATURES
• Also known as tic douloureux
• Characterized by episodic unilateral facial pain in one
or more of the divisions of the trigeminal nerve (cranial
nerve V)
¡ Ophthalmic nerve (V1) provides sensation to the fore-
head and eyes
¡ Maxillary nerve (V2) provides sensation to the cheeks,
upper lip, and roof of the mouth
¡ Mandibular nerve (V3) provides sensation to the jaw
and lower lip and provides movement of the muscles
involved in biting, chewing, and swallowing
• Idiopathic but believed to be the result of compression
of the trigeminal nerve by a vessel or lesion
• Most commonly affects women; typical onset is ages 60
to 70 years
• More commonly affects the right side of the face
• High incidence in patients with multiple sclerosis
• Exacerbations most commonly occur in the fall and spring
CLINICAL ASSESSMENT
• The differential diagnosis includes postherpetic neuralgia,
cluster headache, temporomandibular joint disorder, and
dental abscess
• Patients commonly complain of an unrelenting sinus pain
or toothache lasting for hours, triggered by moving the
jaw or drinking fluids
• Patients may complain of electrical, shock-like pain that
begins to fade within seconds, only to give way to a
burning ache lasting seconds to minutes
• History should focus on pain localization, quality, fre-
quency, and triggers (such as touching the skin lightly,
washing, shaving, brushing teeth, blowing the nose,
drinking hot or cold beverages, encountering a light
breeze, applying makeup, smiling, or talking)
• Patients may be afraid of stimulating a trigger point dur-
ing the physical examination
• Physical examination typically reveals normal findings on
the neurologic examination; sensory loss typically is not
Lindsay Gietzen is an assistant professor and clinical coordinator in
the PA program at Wayne State University in Detroit, Mich. The author
has disclosed no potential conflicts of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000511034.41821.df
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46 www.JAAPA.com
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found unless the patient is checked immediately after a
burst of pain; observe for areas of the face that are neglected
• Any jaw or facial weakness or dysphagia suggests another
cause
DIAGNOSIS
• Thorough history and physical examination
• The diagnostic test of choice is MRI of the brain with
and without contrast to exclude tumors and assess for
causes of compression of the trigeminal nerve
• Diagnostic criteria for trigeminal neuralgia developing
without apparent cause other than neurovascular com-
pression, according to the International Classification of
Headache Disorders, 3rd edition:
¡ Criterion A: At least three attacks of unilateral facial
pain fulfilling criteria B and C
¡ Criterion B: Occurring in one or more divisions of the
trigeminal nerve, with no radiation beyond the tri-
geminal distribution
¡ Criterion C: Pain has at least three of the following
four characteristics:
t Recurring in paroxysmal attacks lasting from a frac-
tion of a second to 2 minutes
QUESTIONS
1. A 60-year-old woman presents to the office with
complaints of episodic stabbing, electrical pain that
courses down the right jawline. The pain started 3
months ago and is triggered by chewing or talking.
She recently went to the dentist and had a normal
examination. Her neurologic examination also is
normal. What is the first-line medication to consider in
this patient?
a. acyclovir
b. carbamazepine
c. ibuprofen
d. hydrocodone
2. Which of the following is an expected physical
examination finding in a patient with trigeminal
neuralgia?
a. facial weakness
b. jaw weakness
c. dysphagia
d. unrelenting pain triggered by moving the jaw
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t Severe intensity
t Electric shock-like, shooting, stabbing, or sharp in
quality
t Precipitated by innocuous stimuli to the affected side
of the face
¡ Criterion D: No clinically evident neurologic deficit
¡ Criterion E: Not better accounted for by another
International Classification of Headache Disorders
diagnosis
TREATMENT
• Medical management
¡ Carbamazepine
¡ Gabapentin (most effective for patients with multiple
sclerosis)
¡ Also consider pregabalin, phenytoin, lamotrigine,
valproic acid, tricyclic antidepressants
• Surgical management
¡ Microvascular decompression (about an 80% success
rate, but most invasive option)
¡ Percutaneous procedures, such as balloon compression,
glycerol rhizotomy, and radiofrequency thermocoagu-
lation (high rate of recurrent pain)
¡ Gamma knife radiosurgery (about a 75% success rate)
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Trigeminal neuralgia
¡ Risks of surgical management include permanent facial
anesthesia and anesthesia dolorosa
• Trigeminal neuralgia may evolve into a chronic pain
syndrome because of its high rate of recurrence after
treatment. Patients also may suffer from depression and
related loss of daily function.
• Patients may choose to limit activities that cause pain,
such as chewing, which could lead to weight loss in
extreme circumstances. JAAPA
cause of pain.
Facial or jaw weakness or dysphagia suggests another
drinking fluids is characteristic of trigeminal neuralgia.
2. D. Unrelenting pain triggered by moving the jaw or
neuralgia.
are not effective in treating pain related to trigeminal
hydrocodone would not be appropriate because they
of trigeminal neuralgia. Acyclovir, ibuprofen, and
antidepressants can be used for medical management
phenytoin, lamotrigine, valproic acid, and tricyclic
1. B. Carbamazepine, gabapentin, pregabalin,
Answers
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