Craniofacial pain
Trigeminal neuralgia
Precise diagnosis. Targeted treatments. A specialist pathway to distinguish classical, secondary and neuropathic forms of trigeminal pain.
When facial pain is truly trigeminal neuralgia
Trigeminal neuralgia is characterised by recurrent, unilateral, brief and very severe attacks, often described as electric shocks or stabbing pain, affecting one or more branches of the trigeminal nerve.
Not all pain in the trigeminal territory is neuralgia. Distinguishing classical, idiopathic and secondary forms from painful trigeminal neuropathy guides imaging, medication and the possible indication for interventional procedures.
FUNCTIONAL ANATOMY
What is the trigeminal nerve?
The trigeminal nerve is the main sensory nerve of the face. It is a mixed nerve: alongside facial sensation, it has motor components involved in chewing.
The presence of sensory and motor fibres makes careful selection of the technique, target and parameters essential: nerve injury may cause permanent sensory deficits or functional impairment.
CLINICAL PRESENTATION
Symptoms of trigeminal neuralgia
Brief, severe attacks, often described as electric shocks.
Pain generally affects only one side of the face.
One or more of the V1, V2 or V3 branches are involved.
Talking, chewing, washing the face or wind may trigger an attack.
In typical forms, there may be pain-free periods between attacks.
DIFFERENTIAL DIAGNOSIS
Clinical forms: not all trigeminal pain is the same
The classification distinguishes classical, idiopathic and secondary forms; concomitant continuous pain may also be present. The term “atypical” is still widely used, but covers different conditions and requires precise assessment.
Typical paroxysmal attacks
- sudden, electric shock-like pain
- brief, clearly defined attacks
- recognisable triggers
- possible pain-free intervals
Continuous pain or atypical features
- persistent or recurrent pain
- a burning or pressure-like component
- less clearly defined distribution
- more variable treatment response
ASSESSMENT
Diagnosis
Diagnosis is primarily clinical and considers pain characteristics, anatomical distribution, onset and triggering factors.
Brain MRI with appropriate assessment of the trigeminal nerve is generally part of the work-up to investigate neurovascular conflict and exclude secondary causes. Imaging findings must be interpreted alongside the clinical history and neurological examination.
AETIOLOGY
Causes
The classical form involves neurovascular compression with morphological changes in the trigeminal nerve root. Secondary forms may be associated with other neurological conditions. When neither a secondary cause nor compression with morphological changes is identified, the condition is classified as idiopathic.
- neurovascular conflict
- demyelinating conditions
- consequences of trauma or surgery
- idiopathic forms
TREATMENT
Four pathways, guided by the diagnosis
Carbamazepine and oxcarbazepine are first-line medicines; tolerability and response guide the choice of alternatives.
Assessment for microvascular decompression in suitable classical cases, alongside other established options.
Selected percutaneous procedures targeting the trigeminal nerve or Gasserian ganglion, when indicated.
Non-lesional techniques considered in selected cases, according to the target and clinical objective.
TRIGEMINAL RADIOFREQUENCY
Neuromodulation and thermal lesioning are different procedures
The indication depends on the diagnosis, the branch involved, any sensory deficits, the available alternatives and the balance between expected benefit and risk.
Pulsed radiofrequency
Aim: neuromodulation.
- does not intentionally create a destructive thermal lesion
- aims to modulate abnormal nerve activity
- considered in selected cases, with more limited evidence than established procedures
- requires individually selected targets and parameters
Thermal radiofrequency
Aim: controlled lesioning of trigeminal fibres.
- may provide rapid relief in suitable patients
- involves sensory risks and, depending on the target, motor or corneal risks
- the risk profile varies with the target and branch treated
- requires careful patient selection and specific informed consent
THE PONOS PATHWAY
Diagnosis before intervention
PONOS Clinic addresses cranial neuralgias and complex or refractory trigeminal pain through differential diagnosis, review of previous treatments and careful selection of interventional procedures.
When to seek specialist assessment
Specialist assessment is indicated when facial pain is severe and recurrent, worsens over time, or treatments are ineffective or poorly tolerated. It is also useful for atypical or persistent forms and suspected cluster headache.
FAQ
Frequently asked questions
How long does a trigeminal neuralgia attack last?
Painful attacks generally last from a few seconds to a few minutes, but may recur many times throughout the day.
Can trigeminal neuralgia be cured?
Medication provides good pain control for many patients. In refractory cases, neurosurgical options or interventional procedures may be considered, depending on the diagnosis.
When is radiofrequency considered?
It may be considered in selected patients with refractory pain or poor tolerance of medication, following a full clinical and imaging assessment.
Scientific references
Selected references for further reading on the diagnosis and treatments discussed on this page.
- Bendtsen L et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019;26:831–849. (Guidelines)
- Royal College of Surgeons of England. Guidelines for the management of trigeminal neuralgia. 2021. (Guidelines)
- Ziegeler C et al. Idiopathic Facial Pain Syndromes—An Overview and Clinical Implications. Dtsch Arztebl Int. 2021;118:81–87. (Clinical review)
Indications depend on the diagnosis and technique: thermal and pulsed radiofrequency have different objectives and evidence bases.