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.
Trigeminal neuralgia (TN) is a chronic neuropathic pain condition. Classic TN is caused by direct neurovascular compromise due to anatomic compression. Secondary TN is caused by another condition such as multiple sclerosis (MS) or a tumor. Idiopathic TN has no identifiable cause despite evaluation. Painful episodes are brief, but frequency and severity may be excruciating and debilitating.1 This article provides a review of the best evidence for TN evaluation and management.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Brain magnetic resonance imaging should be obtained when trigeminal neuralgia is suspected to rule out other causes of symptoms, such as multiple sclerosis or tumor.2,3,10 | C | Consensus, usual practice, and expert opinion in the absence of clinical trials |
| Carbamazepine is the initial drug of choice for trigeminal neuralgia.17,19 | A | Consistent and good-quality systematic reviews with patient-oriented outcomes |
| Surgery is effective for symptom relief in patients who have refractory trigeminal neuralgia pain despite pharmacotherapy.25,26 | B | Consistent and fair-quality data from observational studies reporting patient-oriented outcomes |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
EPIDEMIOLOGY
TN is an uncommon condition with a prevalence of 0.03% to 0.3% and an estimated annual incidence of 4.3 to 8 per 100,000 persons. Between 1% and 2% of patients with TN may have a familial link.2,3
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