Trigeminal Neuralgia: Rapid Evidence Review

Trigeminal neuralgia (TN) is a chronic neuropathic pain condition that causes sudden, brief episodes of electric shock–like, lancinating pain in one or more trigeminal nerve distributions. Facial spasms may occur during intense flare-ups. Trigger zones are small areas where minimal stimulation may precipitate a painful flare-up. Painful episodes of TN are often precipitated by seemingly benign stimuli, such as talking, chewing, light touch, or even a breeze across a trigger zone. Nerve root contact, compression, and subsequent demyelination are implicated as the central underlying pathophysiology. The average age of onset is 50 to 60 years, and incidence increases with age. Diagnosis is based on International Headache Society clinical criteria distinguishing classic, secondary, and idiopathic TN. Classic TN is caused by direct neurovascular compromise due to anatomic compression. Secondary TN is caused by another condition such as multiple sclerosis or a tumor. Idiopathic TN has no identifiable etiology. Examination findings typically are normal between painful episodes. Brain magnetic resonance imaging with and without contrast media is recommended for all patients with suspected TN to rule out key differential diagnoses, such as a tumor, and to determine surgical candidacy. The International Headache Society guidelines encourage tailored treatment based on TN type and etiology. Carbamazepine is the initial drug of choice, and 75% of patients with TN achieve initial symptom control with pharmacotherapy. Refractory TN or intolerable adverse drug effects should prompt a trial of adjunctive drugs and referral for surgical evaluation. Microvascular decompression is more effective in improving or alleviating symptoms of TN than other surgical options.