Clinical Review

Trigeminal neuralgia

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g474 (Published 17 February 2014) Cite this as: BMJ 2014;348:g474
  1. Joanna M Zakrzewska, professor of pain medicine in relation to oral medicine1,
  2. Mark E Linskey, professor of neurological surgery2
  1. 1Facial Pain Unit, Eastman Dental Hospital, UCLH NHS Foundation Trust, London WC1X 8LD, UK
  2. 2Department of Surgery, University of California, Irvine, Orange, CA, USA
  1. Correspondence to: J M Zakrzewska j.zakrzewska{at}ucl.ac.uk
  • Accepted 9 January 2014

Summary points

  • Trigeminal neuralgia is a severe, unilateral, episodic pain of the face that is provoked by light touch; it should be differentiated from dental causes of pain

  • Magnetic resonance imaging (MRI) can distinguish between patients having secondary trigeminal neuralgia related to tumours and that related to multiple sclerosis

  • The first line drug for treatment is either carbamazepine or oxcarbazepine, and doses should be slowly escalated. Neurosurgical options should be discussed at an early stage, but surgery may not be required until quality of life is compromised

  • Microvascular decompression is a major neurosurgical procedure that provides the longest period of pain relief and aims to preserve function of the nerve

  • Percutaneous, palliative destructive procedures and stereotactic radiosurgery can provide temporary relief, but at the risk of facial numbness, which increases with repetition of the procedure

Trigeminal neuralgia is a rare, episodic facial pain that is unilateral, electric shock-like, and provoked by light touch. At first, it is often mistaken as a tooth problem owing to its presentation in the two lower branches of the trigeminal nerve. Patients may undergo unnecessary—and sometimes irreversible—dental treatment before the condition is recognised. Initially, a small dose of an antiepileptic drug (such as carbamazepine) rather than any analgesic drug can provide excellent pain relief. However, up to 10% of patients will not respond to antiepileptic drugs,1 and in rare instances trigeminal neuralgia can be secondary to a brain tumour, multiple sclerosis, or vascular anomalies, which will be identified only on neuroimaging.2 If quality of life becomes impaired and symptoms are uncontrolled with drug treatment, patients should be referred to a neurosurgeon for consideration of surgical management. Studies in Europe have shown that trigeminal neuralgia results in considerable interference with activities of daily living that is comparable to other neuropathic pain conditions,3 and could lead …

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