Trigeminal neuralgia — Rapid | Doctor's Passport Education

Synopsis

Identify the distinctive paroxysmal facial-pain syndrome, detect secondary causes and dangerous mimics, and use carbamazepine and neurosurgical referral safely within current specialist pathways.

Trigeminal neuralgia causes recurrent unilateral electric-shock, stabbing or shooting pain in one or more trigeminal divisions, most often maxillary or mandibular, lasting a fraction of a second to about two minutes.
Innocuous triggers such as light touch, talking, chewing, tooth brushing, shaving or a breeze are characteristic; patients may identify a small trigger zone and pause during attacks.
Classical disease is associated with neurovascular compression that produces morphological change of the trigeminal root; secondary disease arises from multiple sclerosis, tumour or another structural lesion.

Key red flags

Severe flare

Repeated triggers can make swallowing, drinking and oral hygiene impossible, causing dehydration, weight loss and psychological crisis despite a normal examination.

Investigation priorities

Structured pain historyFirst step

Test the syndrome against recognised diagnostic features and common mimics.

Management branches

Clinical diagnosisConfirm phenotype and exclude urgency

A patient reports recurrent unilateral episodes of severe facial pain.

Characterise each attack's quality, duration, distribution and triggers, then ask about rash, vision, dental symptoms, jaw pain, temporal tenderness and cranial autonomic features.
Examine oral structures, temporomandibular joints, trigeminal sensation and the remaining cranial nerves, escalating infection, ocular disease, vasculitis or neurological deficit appropriately.

Poor controlEscalate refractory or intolerant disease

Adequately titrated first-line therapy fails, toxicity occurs or nutrition is threatened.

Key medicines

CarbamazepineA common oral introduction is 100 mg once or twice daily with gradual increments; use the current BNF regimen, lowest effective dose and individualised maximum rather than a fixed template.

OxcarbazepineSpecialists often begin a low divided oral dose and titrate against attacks; exact use follows the local formulary because trigeminal-neuralgia prescribing may be off label.

Open full textbook →Answer 2 questions