Trigeminal Neuralgia Explained: Symptoms, Diagnosis, and the Latest Treatment Options
Key Takeaways
Trigeminal neuralgia causes sudden, electric‑shock facial pain in one or more branches of the trigeminal nerve; attacks are brief, severe, and can be triggered by light touch, chewing, or a breeze. Diagnosis is clinical and guided by standardized criteria.
MRI is recommended to rule out secondary causes and to look for a blood vessel compressing the nerve (neurovascular contact), which can inform treatment planning. High‑resolution sequences are preferred.
First‑line medications are carbamazepine or oxcarbazepine. If these are not tolerated or stop working, other options and procedures (microvascular decompression, radiosurgery, or percutaneous rhizotomy) can provide relief.
Safety note: People with certain Asian ancestries should be screened for the HLA‑B*15:02 gene before starting carbamazepine due to a rare but serious skin reaction risk.
What Is Trigeminal Neuralgia?
Trigeminal neuralgia (TN) is a nerve pain disorder marked by brief, sudden, electric‑shock–like facial pain on one side, often triggered by everyday activities (touch, talking, brushing teeth). TN is categorized as:
Classical TN: usually due to a blood vessel compressing the nerve near the brainstem.
Secondary TN: caused by another condition (e.g., multiple sclerosis or a tumor).
Idiopathic TN: no clear cause found despite testing.
Common symptoms & triggers
Severe, stabbing facial pain lasting seconds to two minutes
Pain in the cheek, jaw, lips, teeth, or gums (one or more trigeminal branches)
Triggered by light touch, chewing, talking, or a breeze
Periods of remission and recurrence are common.
How Trigeminal Neuralgia Is Diagnosed
Clinical criteria: Your history and exam are the foundation. Doctors use established criteria to confirm TN and distinguish it from other facial pain conditions.
MRI of the brain & trigeminal nerve: Recommended to exclude secondary causes and to evaluate for neurovascular contact. Protocols typically include high‑resolution 3D sequences (e.g., CISS/FIESTA) and, when appropriate, contrast enhancement to improve visualization.
When to seek care promptly: New numbness, double vision, weakness, hearing changes, or pain on both sides are atypical and warrant medical review and imaging.
First‑Line Medications
Carbamazepine or oxcarbazepine are the preferred initial treatments and can be very effective for many patients. Dosing is individualized and adjusted based on relief and side effects. Do not start/stop medicines without clinician guidance.
Safety screening: Before starting carbamazepine, patients with ancestry in at‑risk Asian populations should be tested for the HLA‑B*15:02 allele because of increased risk of severe skin reactions (SJS/TEN). Your care team will also discuss other rare blood‑related risks and monitoring.
If first‑line agents aren’t enough or aren’t tolerated: Options may include lamotrigine, baclofen, gabapentin/pregabalin, and in select cases botulinum toxin type A as an add‑on. These choices are tailored to your health profile and response.
Procedures & Surgery (When Medicines Aren’t Enough)
1) Microvascular Decompression (MVD)
What it is: A microsurgical procedure that relieves pressure where a blood vessel touches the trigeminal nerve.
Why consider it: For classical TN with imaging evidence of neurovascular contact, MVD generally offers the most durable relief while preserving facial sensation. Suitability depends on imaging findings and overall health.
2) Stereotactic Radiosurgery (SRS) – e.g., Gamma Knife/CyberKnife
What it is: A non‑incisional, precisely targeted radiation treatment to the trigeminal nerve root.
Why consider it: Often chosen for patients who are older or have medical conditions that make open surgery less ideal; relief may develop over weeks.
3) Percutaneous Rhizotomy – radiofrequency, glycerol, or balloon compression
What it is: Needle‑based procedures through the cheek to selectively disrupt pain fibers.
Why consider it: Can provide rapid relief; however, facial numbness is common, and pain can recur over time—procedures can be repeated if needed. Mayo Clinic
Which option is right for me?
Your plan depends on your TN type, MRI findings, overall health, and how you’ve responded to medications. A consultation with an experienced cranial nerve surgeon helps map the safest, most effective path forward.
Living With TN: Practical Tips
Keep a symptom journal (triggers, frequency, medication response).
Maintain dental and neurologic follow‑up—TN can be mistaken for tooth problems, and coordinated care helps avoid unnecessary procedures.
Seek support—patient organizations and pain specialists can help with coping strategies during flares.
Why Work With Dr. Ramesh P. Babu
Dr. Babu is a New York City neurosurgeon with decades of experience in trigeminal neuralgia and skull base surgery, trained at NIMHANS (M.Ch), NYU, and UPMC (under Dr. Peter Jannetta and Dr. Laligam Sekhar), with advanced training under Prof. Majid Samii (Hannover) and at Queen Square, London. He currently serves as Director of Neurosurgery at BronxCare and sits on the Medical Advisory Board of the Facial Pain Association. Patients are evaluated for the full spectrum of care—from optimized medication plans to MVD, SRS, and percutaneous procedures—to match the right treatment to each case.
FAQ
Is trigeminal neuralgia dangerous?
TN is not life‑threatening, but it can be severely painful. Atypical features (numbness, double vision, weakness, both sides) should be evaluated promptly.
Will I need an MRI?
Most patients do, to rule out secondary causes and to guide decisions about surgery. High‑resolution sequences are important.
What if medications stop working?
That’s common over time. Early discussion of procedural options (MVD, SRS, or percutaneous rhizotomy) helps prevent unnecessary suffering.
What to Do Next
If you’re experiencing electric‑shock facial pain, don’t wait. Schedule a consultation with Dr. Ramesh P. Babu to review your symptoms, MRI, and all treatment options—medical and surgical—so you can choose a plan with confidence.
Sources
International Classification of Headache Disorders (ICHD‑3): diagnostic criteria for trigeminal neuralgia. ICHD-3
European Academy of Neurology (2019) guideline: imaging recommendations, first‑line medications, and when to consider surgery; MVD favored for classical TN. uems-neuroboard.org
AAFP Rapid Evidence Review (2025): overview of symptoms, MRI recommendations, and comparative treatment considerations. AAFP
FDA Carbamazepine label: HLA‑B*15:02 screening and serious dermatologic reaction risk. FDA Access Data
Additional patient‑facing context on treatment options (radiosurgery, rhizotomy).
