Ep 95 – Trigeminal neuralgia

Trigeminal neuralgia (TN) is a condition characterised by severe, shooting pain in the face, along the trigeminal nerve. The pain can be triggered by even mild stimulation of the face, such as brushing teeth, touching the face or eating. It is often described as one of the most excruciating pains known to medicine and it can significantly impact a person's quality of life. The exact cause of trigeminal neuralgia is often unknown and treatment options include carbamazepine or gabapentin, as well as surgical procedures that relieve pressure on the trigeminal nerve or disrupt the pain signals in some cases. In this episode, Dr Roger Henderson looks at what GPs need to know when patients present in surgery with trigeminal neuralgia, when to refer them to secondary care and the prognosis for these patients.

Key references

1. National Institute of Neurological Disorders and Stroke. Trigeminal neuralgia. 7 February 2024.
2. NICE. Clinical guideline. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173). 22 September 2020.
3. NICE. Interventional procedures guidance. Stereotactic radiosurgery for
   trigeminal neuralgia (IPG715). 2 February 2022.

Key take-home points

• TN arises from a disorder of the fifth cranial (trigeminal) nerve.
• It causes severe — sometimes unbearable — pain in the face that can last several minutes.
• It is relatively uncommon under the age of 40, with women being slightly more likely to be affected.
• Compression of the trigeminal nerve is the cause in most cases.
• Bilateral presentations are rare.
• Triggers include shaving, touch, wind blowing on the face and vibration.
• There are multiple differential diagnoses including cluster headaches, migraine and temporomandibular joint dysfunction.
• The diagnosis is clinical and often difficult to make.
• Magnetic resonance imaging scans are a common diagnostic tool.
• There is no definitive cure for TN.
• Normal analgesics, including opioids, are not usually effective and carbamazepine should be the first-line drug of choice.
• There is no evidence that complementary therapies have any place in the management of TN.
• Around three-quarters of people with TN will have a second episode within 10 years.