Trigeminal Neuralgia: Clinical Presentation, Diagnostic Evaluation, Management, and Outcomes – A Case Report

Abstract

Trigeminal neuralgia is a chronic neuropathic pain disorder characterized by recurrent episodes of severe, sudden, electric shock-like facial pain along the distribution of the trigeminal nerve. It is considered one of the most painful neurological conditions and can significantly impair quality of life. The condition commonly affects individuals above 50 years of age and is often associated with neurovascular compression of the trigeminal nerve root.

We present the case of a 56-year-old female who presented with recurrent episodes of severe right-sided facial pain involving the maxillary and mandibular divisions of the trigeminal nerve. The pain was triggered by chewing, speaking, and brushing teeth. Neurological examination was otherwise normal. MRI brain with trigeminal nerve protocol excluded secondary causes and demonstrated vascular compression of the trigeminal nerve. The patient was treated with carbamazepine with significant symptomatic improvement.

This case highlights the importance of early recognition of trigeminal neuralgia, differentiation from dental and other facial pain disorders, and timely initiation of appropriate therapy to improve patient outcomes and quality of life.

Introduction

Trigeminal neuralgia (TN), also known as tic douloureux, is a neuropathic pain syndrome involving the fifth cranial nerve. The disorder is characterized by sudden, unilateral, recurrent episodes of severe facial pain lasting from a few seconds to minutes. The pain is commonly described as stabbing, lancinating, or electric shock-like.

The trigeminal nerve provides sensory innervation to the face through three divisions:

• Ophthalmic (V1)
• Maxillary (V2)
• Mandibular (V3)

Trigeminal neuralgia most commonly affects the maxillary and mandibular divisions. The condition is usually unilateral and rarely bilateral.

The most common mechanism involves vascular compression at the trigeminal nerve root entry zone, resulting in focal demyelination and abnormal neuronal excitability. Secondary causes include multiple sclerosis, tumors, vascular malformations, and cerebellopontine angle lesions.

The annual incidence of trigeminal neuralgia is estimated to be approximately 4–13 cases per 100,000 individuals, with a higher prevalence among females and older adults.

Patients often experience severe pain triggered by otherwise harmless activities such as:

• Chewing
• Talking
• Brushing teeth
• Washing the face
• Cold wind exposure

Prompt diagnosis and early treatment are essential to reduce morbidity and improve quality of life.

Case Report

Patient History

A 56-year-old female presented to the neurology outpatient department with:

• Recurrent episodes of severe right-sided facial pain for 6 months
• Sudden electric shock-like pain over the cheek and jaw
• Pain lasting for a few seconds to 1 minute
• Multiple attacks occurring daily
• Triggering during chewing, brushing teeth, and speaking

The patient reported progressive worsening in frequency and severity of pain episodes.

There was no history of:

• Facial weakness
• Hearing loss
• Visual disturbances
• Fever
• Trauma
• Dental infection

Medical history revealed:

• Hypertension for 8 years
• No diabetes mellitus
• No previous neurological illness

Family history was non-contributory.

Clinical Examination

General Examination

• Patient conscious and oriented
• Blood pressure: 132/84 mmHg
• Pulse rate: 76/min
• Afebrile
• Systemic examination unremarkable

Neurological Examination

Cranial Nerve Examination

• Severe tenderness over right maxillary region during pain episodes
• Trigger zone identified near right nasolabial fold
• Facial sensations preserved
• Corneal reflex intact
• No facial muscle weakness
• No hearing deficits

Motor Examination

• Normal muscle tone and power
• No focal neurological deficit

Cerebellar Examination

• Normal

Meningeal Signs

• Absent

Clinical Evaluation

Differential Diagnosis

Based on history and examination, the following conditions were considered:

• Trigeminal neuralgia
• Dental pain
• Temporomandibular joint dysfunction
• Cluster headache
• Post-herpetic neuralgia
• Migraine
• Sinusitis

The characteristic episodic electric shock-like pain with trigger zones strongly suggested trigeminal neuralgia.

Investigations

Routine Laboratory Tests

• Complete blood count: Normal
• Blood glucose: Normal
• Renal function tests: Normal
• Liver function tests: Normal

MRI Brain with Trigeminal Nerve Protocol

Findings included:

• Vascular loop compressing the right trigeminal nerve root entry zone
• No intracranial mass lesion
• No demyelinating plaques
• No cerebellopontine angle tumor

Dental Evaluation

• No dental abscess
• No significant dental pathology

Diagnosis

Based on clinical features and imaging findings, a diagnosis of:

Classical Trigeminal Neuralgia involving the right maxillary (V2) and mandibular (V3) divisions

was established.

Management and Outcome

Treatment Strategy

The goals of management included:

• Reduction of pain frequency
• Prevention of recurrent attacks
• Improvement in quality of life
• Long-term symptom control

Medical Management

The patient was started on:

• Carbamazepine 100 mg twice daily

​​​​​​​

• Gradual dose escalation based on response
• Vitamin supplementation
• Counseling regarding trigger avoidance

Clinical Course

At 1 Week

• Mild reduction in pain frequency
• Improved oral intake

At 1 Month

• Significant reduction in pain severity
• Only occasional breakthrough episodes
• Improved sleep and daily activities

At 3 Months

• Marked symptomatic improvement
• Minimal pain attacks
• Good drug tolerance
• No neurological deficits

Discussion

Pathophysiology

Trigeminal neuralgia commonly results from vascular compression of the trigeminal nerve root by adjacent arteries or veins. Chronic pulsatile compression leads to focal demyelination and hyperexcitability of trigeminal sensory fibers.

This results in:

• Abnormal ectopic impulse generation
• Ephaptic transmission between nerve fibers
• Severe paroxysmal facial pain

Secondary trigeminal neuralgia may occur due to:

• Multiple sclerosis
• Brain tumors
• Vascular malformations
• Cerebellopontine angle lesions

Epidemiology

• Incidence: 4–13 per 100,000 population annually
• More common in females
• Peak incidence after 50 years
• Right-sided involvement more common
• Bilateral involvement rare

Clinical Manifestations

Typical Symptoms

• Sudden electric shock-like facial pain
• Unilateral involvement
• Brief recurrent episodes
• Triggered by light touch or facial movements

Trigger Factors

• Chewing
• Speaking
• Brushing teeth
• Shaving
• Cold breeze exposure

Commonly Involved Divisions

• Maxillary division (V2)
• Mandibular division (V3)

Diagnostic Considerations

Diagnosis is primarily clinical and supported by imaging.

Important diagnostic tools include:

1. Detailed pain history
2. Neurological examination
3. MRI brain with trigeminal nerve protocol
4. Exclusion of dental and ENT causes

MRI is important to identify secondary causes and vascular compression.

Treatment Modalities

Medical Therapy

First-line medications include:

• Carbamazepine
• Oxcarbazepine

Other agents:

• Gabapentin
• Baclofen
• Lamotrigine

Surgical Options

Indicated in refractory cases:

• Microvascular decompression
• Radiofrequency rhizotomy
• Gamma knife radiosurgery
• Balloon compression

Microvascular decompression provides long-term pain relief in selected patients.

Complications

Potential complications include:

• Chronic debilitating pain
• Anxiety and depression
• Weight loss due to fear of eating
• Medication adverse effects
• Reduced quality of life

Untreated trigeminal neuralgia can significantly impair psychosocial functioning.

Prognosis

The prognosis depends on:

• Early diagnosis
• Response to medical therapy
• Presence of secondary causes
• Duration of symptoms

Most patients initially respond well to carbamazepine therapy. Surgical interventions offer favorable outcomes in medically refractory cases.

In this case, early treatment resulted in substantial symptomatic improvement and restoration of daily functioning.

Conclusion

Trigeminal neuralgia is a severely painful neuropathic facial pain disorder that requires prompt recognition and appropriate management. This case emphasizes the importance of identifying characteristic clinical features such as unilateral electric shock-like facial pain and trigger zones.

MRI evaluation is essential to exclude secondary causes and identify neurovascular compression. Early initiation of anticonvulsant therapy can significantly improve symptoms and quality of life.

Comprehensive clinical evaluation and individualized treatment remain the cornerstone of effective management in trigeminal neuralgia.

References

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2. Maarbjerg S, Di Stefano G, Bendtsen L, Cruccu G. Trigeminal neuralgia – diagnosis and treatment. https://pubmed.ncbi.nlm.nih.gov/29290580/
3. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. https://pubmed.ncbi.nlm.nih.gov/18768918/
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5. Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: The diagnostic evaluation and treatment of trigeminal neuralgia. https://pubmed.ncbi.nlm.nih.gov/18721143/
6. National Institute of Neurological Disorders and Stroke. Trigeminal Neuralgia Information Page. https://www.ninds.nih.gov/
7. American Association of Neurological Surgeons. Trigeminal Neuralgia Overview. https://www.aans.org/

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