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trigeminal neuralgia
Medical expert of the article
Last reviewed: 05.07.2025
Trigeminal neuralgia (pain tic) is a paroxysm of severe, sharp, shooting facial pain due to damage to the 5th pair of cranial nerves.
Diagnosis is based on clinical presentation. The usual treatment for trigeminal neuralgia is carbamazepine or gabapentin; sometimes surgery.
Causes of trigeminal neuralgia
Trigeminal neuralgia develops as a result of pathological pulsations of the intracranial arterial or venous (less often) loop, compressing the root of the V pair at the entrance to the brainstem. Sometimes the disease develops as a result of multiple sclerosis. Trigeminal neuralgia most often affects adults, especially the elderly.
[ Symptoms of trigeminal neuralgia
The pain is shooting, excruciating, often disabling, occurs in the innervation zone of one or more branches of the trigeminal nerve (usually the maxillary) and lasts from seconds to 2 minutes. The pain is often provoked by touching trigger points on the face or movements (e.g. chewing, brushing teeth).
Symptoms of trigeminal neuralgia are pathognomonic. Postherpetic pain is characterized by persistence, typical antecedent rashes, scars, and a tendency to affect the first branch. In migraine, facial pain is usually longer lasting and often pulsates. Neurological examination does not reveal pathology. The appearance of neurological deficit indicates an alternative cause of pain (e.g., tumor, plaque in multiple sclerosis, vascular malformation, other lesions leading to compression of the nerve or pathways in the brainstem, stroke). Damage to the brainstem is indicated by sensory disturbances in the innervation zone of the 5th pair, corneal reflex, and motor function. Loss of pain and temperature sensitivity, loss of corneal reflex with preservation of motor function suggest medullary damage. Deficiency of the V pair is possible in Sjogren's syndrome or rheumatoid arthritis, but only with sensory deficits involving the nose and area around the mouth.
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Treatment of trigeminal neuralgia
In long-standing trigeminal neuralgia, carbamazepine 200 mg orally 3-4 times a day is usually effective; after 2 weeks of treatment and then every 3-6 months, liver function and hematopoiesis should be checked. If carbamazepine is ineffective or has side effects, gabapentin 300-900 mg orally 3 times a day, phenytoin 100-200 mg orally 2-3 times a day, baclofen 10-30 mg orally 3 times a day, or amitriptyline 25-200 mg orally at bedtime are prescribed. Peripheral blockade provides only temporary relief.
If severe pain persists despite these measures, neuroablative treatment of trigeminal neuralgia should be considered. The effectiveness of such treatments for trigeminal neuralgia is temporary, and improvement may result in relapses of persistent pain, even more severe than that for which surgery was undertaken. During posterior fossa craniectomy, a small pad can be placed to isolate the trigeminal nerve root from the pulsating vascular loop. Radiosurgical transection of the proximal segment of the trigeminal nerve with a gamma knife is possible. There are methods of electrolytic and chemical destruction, as well as balloon compression of the trigeminal ganglion (Gasserian ganglion) by percutaneous stereotactic puncture. A measure of desperation is transection of the trigeminal nerve fibers between the Gasserian ganglion and the brainstem.
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