- Zahid H Bajwa, MD
Zahid H Bajwa, MD
- Tufts University Medical School
- Charles C Ho, MD
Charles C Ho, MD
- Staff Anesthesiologist
- Beverly Anesthesia Associates
- Sajid A Khan, MD
Sajid A Khan, MD
- Research Fellow
- Arnold Pain Center, Beth Israel Deaconess Medical Center
- Section Editors
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
- Jerry W Swanson, MD, MHPE
Jerry W Swanson, MD, MHPE
- Section Editor — Headache
- Professor of Neurology
- Mayo Clinic College of Medicine
Trigeminal neuralgia (TN) is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the fifth cranial (trigeminal) nerve that typically are triggered by innocuous stimuli .
An overview of TN is presented here. Other causes of facial pain are discussed separately. (See "Overview of craniofacial pain".)
The trigeminal nerve (figure 1) is the sensory supply to the face and the sensory and motor supply to the muscles of mastication. It has three major divisions:
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
- Katusic S, Williams DB, Beard CM, et al. Epidemiology and clinical features of idiopathic trigeminal neuralgia and glossopharyngeal neuralgia: similarities and differences, Rochester, Minnesota, 1945-1984. Neuroepidemiology 1991; 10:276.
- MacDonald BK, Cockerell OC, Sander JW, Shorvon SD. The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000; 123 ( Pt 4):665.
- Childs AM, Meaney JF, Ferrie CD, Holland PC. Neurovascular compression of the trigeminal and glossopharyngeal nerve: three case reports. Arch Dis Child 2000; 82:311.
- Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol 1990; 27:89.
- Maarbjerg S, Gozalov A, Olesen J, Bendtsen L. Trigeminal neuralgia--a prospective systematic study of clinical characteristics in 158 patients. Headache 2014; 54:1574.
- Fleetwood IG, Innes AM, Hansen SR, Steinberg GK. Familial trigeminal neuralgia. Case report and review of the literature. J Neurosurg 2001; 95:513.
- Pan SL, Yen MF, Chiu YH, et al. Increased risk of trigeminal neuralgia after hypertension: a population-based study. Neurology 2011; 77:1605.
- Siqueira SR, Teixeira MJ, Siqueira JT. Clinical characteristics of patients with trigeminal neuralgia referred to neurosurgery. Eur J Dent 2009; 3:207.
- Teruel A, Ram S, Kumar SK, et al. Prevalence of hypertension in patients with trigeminal neuralgia. J Headache Pain 2009; 10:199.
- Lin KH, Chen YT, Fuh JL, Wang SJ. Increased risk of trigeminal neuralgia in patients with migraine: A nationwide population-based study. Cephalalgia 2015.
- Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain 2001; 124:2347.
- Bowsher D. Trigeminal neuralgia: an anatomically oriented review. Clin Anat 1997; 10:409.
- Hamlyn PJ. Neurovascular relationships in the posterior cranial fossa, with special reference to trigeminal neuralgia. 2. Neurovascular compression of the trigeminal nerve in cadaveric controls and patients with trigeminal neuralgia: quantification and influence of method. Clin Anat 1997; 10:380.
- Cheng TM, Cascino TL, Onofrio BM. Comprehensive study of diagnosis and treatment of trigeminal neuralgia secondary to tumors. Neurology 1993; 43:2298.
- Linskey ME, Jho HD, Jannetta PJ. Microvascular decompression for trigeminal neuralgia caused by vertebrobasilar compression. J Neurosurg 1994; 81:1.
- Ildan F, Göçer AI, Bağdatoğlu H, et al. Isolated trigeminal neuralgia secondary to distal anterior inferior cerebellar artery aneurysm. Neurosurg Rev 1996; 19:43.
- Figueiredo PC, Brock M, De Oliveira AM Júnior, Prill A. Arteriovenous malformation in the cerebellopontine angle presenting as trigeminal neuralgia. Arq Neuropsiquiatr 1989; 47:61.
- Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery 1997; 40:1.
- Haddad FS, Taha JM. An unusual cause for trigeminal neuralgia: contralateral meningioma of the posterior fossa. Neurosurgery 1990; 26:1033.
- Mohanty A, Venkatrama SK, Rao BR, et al. Experience with cerebellopontine angle epidermoids. Neurosurgery 1997; 40:24.
- Love S, Hilton DA, Coakham HB. Central demyelination of the Vth nerve root in trigeminal neuralgia associated with vascular compression. Brain Pathol 1998; 8:1.
- Hilton DA, Love S, Gradidge T, Coakham HB. Pathological findings associated with trigeminal neuralgia caused by vascular compression. Neurosurgery 1994; 35:299.
- Fromm GH, Terrence CF, Maroon JC. Trigeminal neuralgia. Current concepts regarding etiology and pathogenesis. Arch Neurol 1984; 41:1204.
- Obermann M, Yoon MS, Ese D, et al. Impaired trigeminal nociceptive processing in patients with trigeminal neuralgia. Neurology 2007; 69:835.
- Gass A, Kitchen N, MacManus DG, et al. Trigeminal neuralgia in patients with multiple sclerosis: lesion localization with magnetic resonance imaging. Neurology 1997; 49:1142.
- Truini A, Prosperini L, Calistri V, et al. A dual concurrent mechanism explains trigeminal neuralgia in patients with multiple sclerosis. Neurology 2016; 86:2094.
- Meaney JF, Watt JW, Eldridge PR, et al. Association between trigeminal neuralgia and multiple sclerosis: role of magnetic resonance imaging. J Neurol Neurosurg Psychiatry 1995; 59:253.
- Cruccu G, Finnerup NB, Jensen TS, et al. Trigeminal neuralgia: New classification and diagnostic grading for practice and research. Neurology 2016; 87:220.
- Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014; 348:g474.
- Sjaastad O, Pareja JA, Zukerman E, et al. Trigeminal neuralgia. Clinical manifestations of first division involvement. Headache 1997; 37:346.
- Pareja JA, Barón M, Gili P, et al. Objective assessment of autonomic signs during triggered first division trigeminal neuralgia. Cephalalgia 2002; 22:251.
- Fromm GH, Graff-Radford SB, Terrence CF, Sweet WH. Pre-trigeminal neuralgia. Neurology 1990; 40:1493.
- Evans RW, Graff-Radford SB, Bassiur JP. Pretrigeminal neuralgia. Headache 2005; 45:242.
- Wright E, Evans J. Oral pre-trigeminal neuralgia pain: clinical differential diagnosis and descriptive study results. Cranio 2014; 32:193.
- von Eckardstein KL, Keil M, Rohde V. Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurg Rev 2015; 38:355.
- Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008; 71:1183.
- Goh BT, Poon CY, Peck RH. The importance of routine magnetic resonance imaging in trigeminal neuralgia diagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:424.
- Antonini G, Di Pasquale A, Cruccu G, et al. Magnetic resonance imaging contribution for diagnosing symptomatic neurovascular contact in classical trigeminal neuralgia: a blinded case-control study and meta-analysis. Pain 2014; 155:1464.
- Lambru G, Matharu MS. SUNCT, SUNA and trigeminal neuralgia: different disorders or variants of the same disorder? Curr Opin Neurol 2014; 27:325.
- Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ 2007; 334:201.
- Wiffen PJ, Derry S, Moore RA, Kalso EA. Carbamazepine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2014; :CD005451.
- Campbell FG, Graham JG, Zilkha KJ. Clinical trial of carbazepine (tegretol) in trigeminal neuralgia. J Neurol Neurosurg Psychiatry 1966; 29:265.
- Rockliff BW, Davis EH. Controlled sequential trials of carbamazepine in trigeminal neuralgia. Arch Neurol 1966; 15:129.
- Killian JM, Fromm GH. Carbamazepine in the treatment of neuralgia. Use of side effects. Arch Neurol 1968; 19:129.
- Nicol CF. A four year double-blind study of tegretol in facial pain. Headache 1969; 9:54.
- Fromm GH, Terrence CF, Chattha AS. Baclofen in the treatment of trigeminal neuralgia: double-blind study and long-term follow-up. Ann Neurol 1984; 15:240.
- Zakrzewska JM, Chaudhry Z, Nurmikko TJ, et al. Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a double-blind placebo controlled crossover trial. Pain 1997; 73:223.
- Lunardi G, Leandri M, Albano C, et al. Clinical effectiveness of lamotrigine and plasma levels in essential and symptomatic trigeminal neuralgia. Neurology 1997; 48:1714.
- Lechin F, van der Dijs B, Lechin ME, et al. Pimozide therapy for trigeminal neuralgia. Arch Neurol 1989; 46:960.
- Zhang J, Yang M, Zhou M, et al. Non-antiepileptic drugs for trigeminal neuralgia. Cochrane Database Syst Rev 2013; :CD004029.
- Niki Y, Kanai A, Hoshi K, Okamoto H. Immediate analgesic effect of 8% lidocaine applied to the oral mucosa in patients with trigeminal neuralgia. Pain Med 2014; 15:826.
- Fromm GH, Aumentado D, Terrence CF. A clinical and experimental investigation of the effects of tizanidine in trigeminal neuralgia. Pain 1993; 53:265.
- Lindström P, Lindblom U. The analgesic effect of tocainide in trigeminal neuralgia. Pain 1987; 28:45.
- Sindrup SH, Jensen TS. Pharmacotherapy of trigeminal neuralgia. Clin J Pain 2002; 18:22.
- Braham J, Saia A. Phenytoin in the treatment of trigeminal and other neuralgias. Lancet 1960; 2:892.
- McCleane GJ. Intravenous infusion of phenytoin relieves neuropathic pain: a randomized, double-blinded, placebo-controlled, crossover study. Anesth Analg 1999; 89:985.
- Cheshire WP. Fosphenytoin: an intravenous option for the management of acute trigeminal neuralgia crisis. J Pain Symptom Manage 2001; 21:506.
- Peiris JB, Perera GL, Devendra SV, Lionel ND. Sodium valproate in trigeminal neuralgia. Med J Aust 1980; 2:278.
- Karlov VA, Savitskaia ON. [Comparative effectiveness of antiepileptic preparations in the treatment of patients with trigeminal neuralgia]. Zh Nevropatol Psikhiatr Im S S Korsakova 1980; 80:530.
- Khan OA. Gabapentin relieves trigeminal neuralgia in multiple sclerosis patients. Neurology 1998; 51:611.
- Obermann M, Yoon MS, Sensen K, et al. Efficacy of pregabalin in the treatment of trigeminal neuralgia. Cephalalgia 2008; 28:174.
- Pérez C, Navarro A, Saldaña MT, et al. Patient-reported outcomes in subjects with painful trigeminal neuralgia receiving pregabalin: evidence from medical practice in primary care settings. Cephalalgia 2009; 29:781.
- Caccia MR. Clonazepam in facial neuralgia and cluster headache. Clinical and electrophysiological study. Eur Neurol 1975; 13:560.
- Court JE, Kase CS. Treatment of tic douloureux with a new anticonvulsant (clonazepam). J Neurol Neurosurg Psychiatry 1976; 39:297.
- Zvartau-Hind M, Din MU, Gilani A, et al. Topiramate relieves refractory trigeminal neuralgia in MS patients. Neurology 2000; 55:1587.
- Reder AT, Arnason BG. Trigeminal neuralgia in multiple sclerosis relieved by a prostaglandin E analogue. Neurology 1995; 45:1097.
- Scrivani SJ, Chaudry A, Maciewicz RJ, Keith DA. Chronic neurogenic facial pain: lack of response to intravenous phentolamine. J Orofac Pain 1999; 13:89.
- Guardiani E, Sadoughi B, Blitzer A, Sirois D. A new treatment paradigm for trigeminal neuralgia using Botulinum toxin type A. Laryngoscope 2014; 124:413.
- Wu CJ, Lian YJ, Zheng YK, et al. Botulinum toxin type A for the treatment of trigeminal neuralgia: results from a randomized, double-blind, placebo-controlled trial. Cephalalgia 2012; 32:443.
- Zakrzewska JM. Botulinum toxin for trigeminal neuralgia--do we have the evidence? Cephalalgia 2012; 32:1154.
- Zakrzewska JM, Akram H. Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Cochrane Database Syst Rev 2011; :CD007312.
- Heros RC, Heros DA, Schumacher, et al. Principles of neurosurgery. In: Neurology in Clinical Practice, Bradley WG, Daroff RB, Fenichel GM (Eds), Butterworth Heinemann, Philadelphia 2004. p.963.
- Jannetta PJ. Microsurgical management of trigeminal neuralgia. Arch Neurol 1985; 42:800.
- Barker FG 2nd, Jannetta PJ, Bissonette DJ, et al. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996; 334:1077.
- Zakrzewska JM, Lopez BC, Kim SE, Coakham HB. Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia. Neurosurgery 2005; 56:1304.
- Broggi G, Ferroli P, Franzini A, et al. Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2000; 68:59.
- Piatt JH Jr, Wilkins RH. Microvascular decompression for tic douloureux. Neurosurgery 1984; 15:456.
- Barker FG 2nd, Jannetta PJ, Bissonette DJ, Jho HD. Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia. Neurosurgery 1997; 40:39.
- Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia. Neurosurgery 2004; 54:973.
- Mittal B, Thomas DG. Controlled thermocoagulation in trigeminal neuralgia. J Neurol Neurosurg Psychiatry 1986; 49:932.
- Zakrzewska JM, Jassim S, Bulman JS. A prospective, longitudinal study on patients with trigeminal neuralgia who underwent radiofrequency thermocoagulation of the Gasserian ganglion. Pain 1999; 79:51.
- North RB, Kidd DH, Piantadosi S, Carson BS. Percutaneous retrogasserian glycerol rhizotomy. Predictors of success and failure in treatment of trigeminal neuralgia. J Neurosurg 1990; 72:851.
- de Siqueira SR, da Nóbrega JC, de Siqueira JT, Teixeira MJ. Frequency of postoperative complications after balloon compression for idiopathic trigeminal neuralgia: prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102:e39.
- Young RF, Vermeulen SS, Grimm P, et al. Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related. Neurology 1997; 48:608.
- Nurmikko TJ, Eldridge PR. Trigeminal neuralgia--pathophysiology, diagnosis and current treatment. Br J Anaesth 2001; 87:117.
- Sheehan J, Pan HC, Stroila M, Steiner L. Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors. J Neurosurg 2005; 102:434.
- Flickinger JC, Pollock BE, Kondziolka D, et al. Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study. Int J Radiat Oncol Biol Phys 2001; 51:449.
- Maesawa S, Salame C, Flickinger JC, et al. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 2001; 94:14.
- Petit JH, Herman JM, Nagda S, et al. Radiosurgical treatment of trigeminal neuralgia: evaluating quality of life and treatment outcomes. Int J Radiat Oncol Biol Phys 2003; 56:1147.
- Régis J, Metellus P, Hayashi M, et al. Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia. J Neurosurg 2006; 104:913.
- Lopez BC, Hamlyn PJ, Zakrzewska JM. Stereotactic radiosurgery for primary trigeminal neuralgia: state of the evidence and recommendations for future reports. J Neurol Neurosurg Psychiatry 2004; 75:1019.
- Smith ZA, Gorgulho AA, Bezrukiy N, et al. Dedicated linear accelerator radiosurgery for trigeminal neuralgia: a single-center experience in 179 patients with varied dose prescriptions and treatment plans. Int J Radiat Oncol Biol Phys 2011; 81:225.
- Chen JC, Girvigian M, Greathouse H, et al. Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results. J Neurosurg 2004; 101 Suppl 3:346.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL FEATURES
- Diagnostic criteria
- DIFFERENTIAL DIAGNOSIS
- MEDICAL THERAPY
- Other medications
- Refractory pain
- - Botulinum toxin injections
- SURGICAL THERAPY
- Microvascular decompression
- Peripheral neurectomy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS