Practice Summaries of BMJ Clinical Evidence

Trigeminal neuralgia

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1238 (Published 12 March 2015) Cite this as: BMJ 2015;350:h1238
  1. Joanna M Zakrzewska, consultant and professor, facial pain unit1,
  2. Mark E Linskey, professor of neurological surgery2
  1. 1Division of Diagnostic, Surgical and Medical Sciences, Eastman Dental Hospital, London, UK
  2. 2Department of Surgery, University of California Irvine, Irvine, California, USA
  1. Correspondence to: J M Zakrzewska j.zakrzewska{at}ucl.ac.uk

The bottom line

  • Trigeminal neuralgia is characterised by sharp stabbing pains that are usually unilateral, last for less than a minute, and occur within the distribution of the fifth cranial nerve

  • Few high quality, large randomised control trials are available to guide practice

  • Initial treatment is usually medical with a single first line agent (such as carbamazepine or oxcarbazepine)

  • Consider surgical treatment if an adequate trial of a single first line agent at maximum tolerable dose has failed

Trigeminal neuralgia is a characteristic pain in the distribution of one or more branches of the fifth cranial nerve. Diagnosis is made on history alone: pain occurs in paroxysms, each pain lasts from a few seconds to several minutes, and no pain is experienced in between. The frequency of attacks ranges from four or five to hundreds a day, attacks can occur daily for weeks or months, or there can be months or years of pain remission. Pain is severe and described as intense, sharp, stabbing, or shooting—often like an electric shock. It can be triggered by light touch in any area innervated by the trigeminal nerve. Triggers include eating, talking, washing the face, wind, and cleaning the teeth. The condition can impair activities of daily living and lead to depression. Some people experience background pain of lower intensity for 50% of the time; this form of the disease is termed atypical trigeminal neuralgia, type 2 trigeminal neuralgia, or trigeminal neuralgia with concomitant pain.1 Neurological examination is usually normal but sensory and autonomic symptoms may be reported,1 and people with a long history of the disease may show subtle …

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