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Recognise and Manage Trigeminal Neuralgia in General Practice

Dr Carolina Venda Nova and Professor Joanna M. Zakrzewska Discuss Current Guidance on Trigeminal Neuralgia, Covering Diagnosis, Referral, and Shared Care

Read This Article to Learn More About:
  • the key features of trigeminal neuralgia (TN) that guide diagnosis and referral
  • initial treatment and investigation of TN, including first-line pharmacotherapy with carbamazepine
  • the role of the GP in ongoing management, particularly in providing advice and support to patients experiencing an acute attack.
Key points can be found at the end of this article.

Reflect on your learning and download our Reflection Record.

Trigeminal neuralgia (TN) is a rare disorder in which a person feels brief attacks of severe pain in their face. It is usually first seen in either general practice or primary dental practice, occurs most frequently in people over 50 years of age, and is more prevalent in women than men.1

TN is a complex, long-term condition requiring a multidisciplinary approach. However, patients with symptoms of TN may be referred to a wide variety of specialists, and it can take several years before they see a specialist who follows current guidance. 

TN is associated with serious pain and uncertainty, and can have a significant impact on a person's quality of life (QOL) and mood, especially if it is poorly managed.1–5 Studies have shown that patients with TN are at increased risk of anxiety, depression, and poor sleep;1 in turn, these factors increase their risk of suicide.2

Specialists rely on GPs for shared care.1,4 Therefore, it is important that primary care clinicians are aware of the condition and able to identify, manage, and refer patients with suspected TN appropriately. This article will describe the main features of TN, and explain how national guidelines can be used to ensure its optimal treatment by specialists and GPs on a shared-care basis.

Key Features and Diagnosis

TN is a unilateral, episodic condition that presents with severe attacks of facial pain usually lasting from a few seconds to a few minutes.4,6 These attacks can be spontaneous, but may also be triggered by light touches to the face, such as from eating, showering, or cold wind.4,5,7 The first attack of pain is often memorable, as it tends to be sudden and severe.4 

It is the severity of the pain that prompts a person to see their GP, but—as the pain is often felt inside the mouth—they may instead see a dentist, who will inevitably look for a dental cause.4,8 Many patients will therefore undergo multiple, irreversible dental treatments before receiving a diagnosis, such as filling replacements, root canal therapy, or tooth extractions, none of which will resolve the issue.8

Initially, patients can experience anything from one to 50 attacks per day, many of which are of high intensity.1 Sometimes, the attacks will abate after a few weeks, but usually they continue until some form of medication is provided.1,4,5 Even if a period of remission occurs, the pain usually returns after several weeks or months, or occasionally years.1,4,9

Diagnosing TN

A diagnosis of TN is made based on a detailed clinical history and clinical examination, but it can be more challenging to make in primary care—especially at first presentation—as the patient's pain history tends to be shorter.4,5 However, with time, patients usually go into remission,4,9 and this feature may aid a clinician in diagnosis. 

Table 1 includes a few key questions to ask when considering a diagnosis of TN. It is best practice for any case of TN to be assessed and confirmed by a specialist.3–6,9

Table 1: Key Diagnostic Questions, Corresponding to the ICHD Diagnostic Criteria3–6,9

Question for patient

InterpretationICHD diagnostic criteria
Do you remember exactly where you were or what you were doing the moment your facial pain started?TN is usually associated with a memorable onset, and this is often reported by patientsParoxysms of unilateral facial pain, precipitated by an innocuous stimulus
Did the pain begin suddenly?Sudden pain is much more likely in TN than dental pain with gradual onsetParoxysms of unilateral facial pain

Are these attacks very severe?

Consider using a scale of 0–10

First attacks are often very severe, and are the reason why patients are prompted to attendSevere intensity
Has a dentist told you that that your episodic pain is not coming from the teeth?This is important to check, as dental pain is very commonNot accounted for by any other diagnosis
Do any of these words reflect your pain?—shooting, stabbing, electric-shock like, burning, throbbing, achingPatients will often choose these words without prompting, particularly shooting, stabbing, and 'like an electric shock'Pain feels like an electric shock, and/or is shooting, stabbing, or sharp in quality

Where do you feel the pain? 

A diagram may be helpful

Pain should usually be on one side of the face, most frequently in the maxilla and/or mandible, but rarely in the ophthalmic division of the trigeminal nerveUnilateral face pain, distributed in one or more divisions of the trigeminal nerve
Do you feel the pain inside your mouth?Many people will report pain intraorally, but not to the back of the tonguePain in the distribution of the trigeminal nerve, not radiating beyond
How long is each attack?Individual attacks of TN should last for seconds, or at the most for 2 minutes, although a person can have a series of stabbing attacks over a longer periodPain lasts for between a fraction of a second and 2 minutes
How many attacks of pain do you get per day?Around 10 attacks are expected per day, but it could be moreRecurrent paroxysms of pain
What can trigger your pain?—e.g. brushing your teeth, eating, talking, washing your faceLight touch activities usually trigger the pain, as does eatingPain is precipitated by innocuous stimuli within the affected area
ICHD=International Classification of Headache Disorders; TN=trigeminal neuralgia

Secondary Causes and Differential Diagnoses

When assessing suspected TN, it is crucial to determine whether there could be a secondary cause.3,5 Secondary causes include multiple sclerosis (MS) and brain tumours.1,3,4,10 

TN can be the first presenting symptom of MS, and in some patients may be associated with sensory loss.10 A brain tumour, often a benign tumour such as a meningioma or a schwannoma, can also present with hearing loss and TN.11,12 A history of malignancy or the existence of other systemic symptoms, such as fever and weight loss, should prompt early referral to the appropriate specialist services, as should the following 'red flags':4 

  • sensory or motor deficits
  • deafness or other ear problems
  • optic neuritis
  • bilateral TN pain
  • presentation in a person aged under 30 years.
Dental problems can mimic the symptoms of TN, so it is useful for patients to be seen by a dental professional.4,8 In particular, cracked teeth and unilateral temporomandibular disorders (TMDs) are conditions commonly seen by dentists, and should feature in the differential diagnosis.4,5 Patients with TN can also have TMD as a comorbidity,13 which could be caused by uneven use of their jaw.

Guidelines on TN

International guidelines for the management of TN have been in existence since 2008, and an updated version of European guidance was published in 2019.3 These guidelines did not involve patients or other relevant stakeholders. 

In 2021, a UK national guideline was published with the support of the Faculty of Dental Surgery of the Royal College of Surgeons of England. It was developed with input from major stakeholders in primary and secondary care, as well as from patients.4

Initial Management 


At diagnosis, all patients should undergo imaging, preferably magnetic resonance imaging (MRI), to identify any underlying pathology or neurovascular compression.3,4 Ideally, this would be performed in a specialist centre.3,4 If MRI is not possible, computed tomography can be used instead to exclude an underlying pathology.3,4

Optimising Treatment

As a wide range of treatments is available for TN, it is helpful to use patient-related outcome measures to guide management.4,14 The most important outcomes of TN management, as identified by patients and experts, include pain relief, pain interference, side effects of treatment, health-related QOL, satisfaction with treatment, and the ability to participate in social roles and activities.15 Patients should be encouraged to keep pain diaries, as they can help to gauge the effectiveness of treatment and inform medication adjustments and treatment escalation.4 

Providing Information to Patients

When providing information to a patient about TN and its management, a clinician may wish to show them the national guideline, which includes a lay summary.4 It may also be useful to give patients separate written information about TN as well, covering both pharmacological and surgical options.4 The Brain and Spine Foundation, for example, offers a booklet covering all forms of facial pain, in particular TN—

Pharmacological Management

Carbamazepine and oxcarbazepine

Carbamazepine is seen as the gold standard for initial pharmacological management, and is recommended for TN in NICE guidance on the management of neuropathic pain in nonspecialist care.3,17 However, the NICE guideline does not provide any guidance on prescribing.17 With carbamazepine, it is important to start with low doses10—the British National Formulary (BNF) recommends 100 mg one to two times per day, to be increased gradually according to response to a usual dose of 200 mg three to four times a day, up to a maximum of 1.6 g daily (if necessary).18 

If carbamazepine cannot reach the therapeutic dose owing to intolerable side effects, if it fails to provide adequate pain relief, or if there is an absolute contraindication due to a drug interaction, oxcarbazepine can be prescribed, with a therapeutic range that is usually between 1200 and 1800 mg/day, separated into four doses.4 Oxcarbazepine is likely to be more effective than gabapentin or pregabalin. GPs can prescribe oxcarbazepine, although its use for TN is off licence; NICE guidance states that, if initial treatment with carbamazepine is unsuccessful, advice should be sought from a specialist.17

In the initial stages, carbamazepine can be considered a diagnostic drug, with many cases of TN responding quickly and effectively.3 However, side effects are common.3,4,18 Moreover, as carbamazepine is eliminated by the cytochrome P450 system, drug interactions with it are also common19—clinicians should be mindful of this, and be sure to check the BNF when prescribing.

When considering a carbamazepine or oxcarbazepine prescription, testing for the presence of the HLA-B*1502 allele is recommended in individuals of Han Chinese or Thai origin, as there is an increased risk of carbamazepine-induced Stevens–Johnson syndrome in this group.4,18,20,21

Alternative Drugs

Even though the pain from TN can be very severe, use of opioids is not recommended as they are ineffective for the management of TN.3,4 Other drugs, such as amitriptyline, gabapentin, and pregabalin, are alternatives to carbamazepine, but are much less likely to be effective in the early stages and should only be initiated by specialists.4 Some patients may also need to take more than one anti-epileptic drug.4 In any case, if treatment has failed with carbamazepine monotherapy, patients should be referred to specialist centres for further guidance and treatment.4,17 

Table 2 provides details of the main drugs indicated for TN.4,5,7,18,21–27 When prescribing, all healthcare professionals should consult the relevant BNF pages and summaries of product characteristics, particularly when considering off-licence use, and should provide patients and carers with written information and a dosage schedule.4 Specialists should also share information on medication schedules with a patient's GP, as they are often asked to continue drugs on prescription and arrange blood tests for monitoring. 

There is some flexibility around dosage escalation should a flare-up occur suddenly.4 Adjuvant medications can be prescribed for acute attacks (see Relapses and Acute Therapy, below).4,5

Table 2: Drug Therapy for TN4,5,7,18,21–27

DrugSuggested initial dosage[A]Suggested maintenance dosage[A]Common side effectsBaseline investigations and monitoring (based on the authors' experience)
First-line treatment


100 mg one to two times per day[18]200 mg three to four times per day, increased if necessary up to 1.6 g daily[18]

Refer to the BNF[18]and the RCS guideline[4] for more information on dose division for TN

Dizziness, drowsiness, dry mouth, eosinophilia, fatigue, fluid imbalance, gastrointestinal discomfort, headache, hyponatraemia, leucopenia, movement disorders, nausea, oedema, skin reactions, thrombocytopaenia, vision disorders, vomiting, weight increaseBaseline tests: 

After 6 months, repeat FBC, U&E, and LFTs; warn of weight gain 

Once stable, repeat U&E tests every 6 months and LFTs periodically


300 mg two times per day with a 300 mg dose increase every 3 days[5]1200–1800 mg per day[5]

Refer to Lambru et al for more information on dose and dose division for TN[5]

Abdominal pain, agitation, alopecia, asthenia, ataxia, impaired concentration, constipation, depression, diarrhoea, dizziness, drowsiness, emotional lability, headache, hyponatraemia, nausea, nystagmus, skin reactions, vertigo, vision disorders, vomitingAs for carbamazepine, with more emphasis on U&Es
Second-line treatment 


25 mg two times per day[5]25–400 mg per day[5] 

Refer to Lambru et al[5] and the RCS guideline[4] for more information on dose division for TN

Aggression, agitation, arthralgia, diarrhoea, dizziness, drowsiness, dry mouth, fatigue, headache, irritability, nausea, pain, rash, sleep disorders, tremor, vomitingFBC, U&E, and LFTs annually


15 mg three times per day[5]15–90 mg three times per day[5]

Refer to Lambru et al,[5] the RCS guideline,[4] and the BNF[24] for more information on dose and dose division for TN

Confusion, constipation, depression, diarrhoea, dizziness, drowsiness, dry mouth, euphoric mood, hallucination, headache, hyperhidrosis, hypotension, nausea, paraesthesia, skin reactions, urinary disorders, vision disorders, vomitingFBC, U&E, and LFTs annually


150 mg two times per day[5]150–600 mg per day[5]

Refer to Lambru et al,[5] the RCS guideline,[4] and the BNF[25] for more information on dose division for TN

Abdominal distension, abnormal appetite, asthenia, cervical spasm, impaired concentration, confusion, constipation, diarrhoea, dizziness, drowsiness, dry mouth, feeling abnormal, abnormal gait, gastrointestinal disorders, headache, increased risk of infection, joint disorders, memory loss, altered mood, movement disorders, muscle complaints, nausea, oedema, pain, abnormal sensation, sexual dysfunction, sleep disorders, speech impairment, vertigo, vision disorders, vomiting, weight changesFBC, U&E, and LFTs annually

Monitor for side effects 


300 mg three times per day[5]300–3600 mg per day[5]

Refer to Lambru et al,[5] the RCS guideline,[4] and the BNF[26] for more information on dose division for TN

Anxiety, abnormal appetite, arthralgia, asthenia, abnormal behaviour, confusion, constipation, cough, depression, diarrhoea, dizziness, drowsiness, dry mouth, dysarthria, dyspnoea, emotional lability, fever, flatulence, abnormal gait, gastrointestinal discomfort, headache, hypertension, increased risk of infection, insomnia, leucopenia, malaise, memory loss, movement disorders, muscle complaints, nausea, nystagmus, oedema, pain, abnormal reflexes, abnormal sensation, sexual dysfunction, skin reactions, abnormal thinking, tooth disorder, tremor, vasodilation, vertigo, visual impairment, vomitingFBC, U&E, and LFTs annually
[A] The dosages suggested here reflect the need for gradual titration to minimise any adverse effects and achieve an optimal response. The final therapeutic dose and choice of drug(s) will vary from patient to patient. GPs should discuss and agree changes in dosages of medicines initiated in secondary care with specialists

[B] The use of this drug for TN is currently off licence

[C] This is a Class C controlled substance

TN=trigeminal neuralgia; BNF=British National Formulary; RCS=Royal College of Surgeons; FBC=full blood count; U&E=urea and electrolytes; LFT=liver function test

Relapses and Acute Therapy

There is little available evidence on the natural history of TN, including on the length of remission and relapse periods. It is therefore difficult to provide a prognosis. Nevertheless, the national guideline recommends that patients slowly reduce and stop their medication when they are in a period of remission—that is, more than 4 weeks with no attacks.4 Some patients will be fearful of doing this, and may prefer to remain on a low dose of their medication.4

Relapses can start suddenly, and therefore require prompt action, often by a GP. Usually, it is best practice to restart the patient's last-used medication.4 If this is not effective, particularly for an acute exacerbation of pain, other drugs may need to be offered.3,4 Occasionally, it will be necessary to combine two drugs.3,4


Lidocaine can be helpful for relieving acute exacerbations, and can be bought over the counter or given via prescription as a spray or an ointment.4,5,28 Lidocaine is most useful for intraoral use if there is an intraoral trigger, and can be particularly helpful for patients who have difficulty eating and brushing their teeth.4 

A dentist, oral surgeon, or TN specialist could also give a patient a local anaesthetic injection (lidocaine, with or without adrenaline) into the trigger-point area, which can be combined with a longer-acting agent such as bupivacaine.4 This would only provide a few hours of pain relief, but can be repeated daily until systemic drugs have reached their effective dose.4 

In severe flare-ups, especially when associated with dehydration, patients should be admitted for treatment, ideally to a setting where a neurology team is available.3,4 These patients may require emergency surgery or intravenous medication.3,4


TN is one of the few chronic pain conditions in which surgical options can result in better outcomes than medical management.4,14 Surgery is a common choice for people with TN; in fact, a recent study conducted at a large teaching hospital found that over 50% of its patients with TN underwent surgery.14 However, surgery is irreversible, is associated with complications, and is not always fully effective—in the study, of those who underwent surgery, 55% of patients were free of pain and no longer taking medication, meaning that almost half of patients who underwent surgery were still affected by TN.14 Careful diagnosis is therefore imperative.

Patients should discuss surgical options early and while they are stable,3,4 so that they can think through their options in a rational way. It can be useful to give patients a decision aid such as the Ottawa Personal Decision Guide,29 which can help them in discussions with other patients, family members, and healthcare professionals.4,14

There is no strong evidence concerning the best time for surgery, but the following need to be considered:3–5

  • use of multiple medications with diminishing efficacy
  • poor tolerability of medication
  • significant impact on mood and QOL.
Of all the available procedures, only microvascular decompression (MVD)—a major neurosurgical procedure—aims at preserving the trigeminal nerve and removing one of the possible causes of the condition, a large vessel pressing on the nerve.3–5 All other procedures are termed ablative or destructive, as they aim to damage pain fibres, and can result in sensory loss.3–5 

Complications After Surgery 

Cerebrospinal Fluid Leak

Patients may develop a cerebrospinal fluid leak 7–10 days after MVD, which can manifest itself as a leak through the wound, ear, or nose, and must be dealt with promptly by the neurosurgeon who carried out the procedure.4,14

Sensory loss

The most significant long-term complication of surgery is sensory loss.4,5 This can vary in severity and distribution, and needs to be addressed and managed appropriately. The most severe form is anaesthesia dolorosa,3,5 a condition in which the patient feels complete numbness in the area innervated by the trigeminal nerve with an added continuous sharp pain. Some patients tolerate mild sensory changes, but in others they can lead to continued use of neuropathic drugs and a significant impact on mood and QOL.3,4 

Patients who have lost their corneal reflex need to be given precise instructions on eye care and encouraged to wear glasses with side plates when going out in windy conditions.4 Hearing loss can be temporary, but in some will be permanent; unfortunately, little can be done about this.14


As surgical procedures are not curative, relapses are likely to occur. In some cases, these can be managed with drug therapy; in others, repeat surgery can be performed.1 

Other Support

It is now recognised that the pain, unpredictability, and reduced ability to carry out daily activities associated with TN are likely to have significant effects on a person's mental health, resulting in depression and anxiety.1,3,4 Therefore, patients will benefit from access to pain-management programmes,1,4 which can help them to improve their QOL.3,4,17

Specialist centres will often have clinical nurse specialists (CNSs), who are independent prescribers and can therefore arrange telephone consultations and advise patients on managing their medication.4 CNSs can also discuss the adjustment of drug dosages and prescriptions with GPs.4

Outside of healthcare services, people with TN may benefit from talking to other people with the condition.1,4 Trigeminal Neuralgia Association UK (TNA UK) is a charity offering help and support to people with TN, and offers a dedicated helpline run by volunteers.4,30 TNA UK also organises webinars, local support groups, and an annual conference. The charity is supported by a medical advisory board.


TN is a condition of unilateral, severe, episodic, facial pain that is provoked by light touch. Initially, it is usually well controlled with carbamazepine. National guidance provides details for both primary and secondary care practitioners on diagnosis, investigation, and management, which can be both pharmacological and surgical.

Key Points
  • When a patient presents with severe, short-lasting, unilateral attacks of facial pain, a diagnosis of TN should be considered
  • The first-line treatment for TN is carbamazepine, with an initial dose of 100–200 mg up to three times a day; there are other pharmacological options available if carbamazepine fails to achieve pain control (see Table 2), which are usually initiated in secondary care
  • Referral to a specialist centre for investigation and management should be considered early
  • Ideally, patients with a diagnosis of TN should have an MRI scan to assess for the presence of neurovascular contact with the trigeminal nerve and to exclude secondary causes of TN (particularly MS and malignancy)
  • There are many surgical options for the management of TN, but not all patients will need surgery
  • Both medical and surgical treatments for TN have associated side effects, and patients should be provided with information on any treatment being offered to them
  • Acute attacks of TN can happen after periods of remission—GPs and dentists can support patients by offering systemic and topical treatment options, notably lidocaine; however, if the patient becomes dehydrated and/or is refractory to medication, hospital admission is advised
  • TN is an unpredictable disease and patients need support in achieving both adequate pain control and a good QOL; the emphasis should be on minimising the impact of pain on the patient's daily life, including any social roles and activities
  • TN can have a significant impact on mental as well as physical health, and patients may benefit from talking to others with the condition or being referred for pain-management programmes.
TN=trigeminal neuralgia; MRI=magnetic resonance imaging; MS=multiple sclerosis; QOL=quality of life
Note: At the time of publication (July 2023), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
Implementation Actions for Clinical Pharmacists in General Practice

Written by Shivangee Maurya, Clinical Services Pharmacist, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing guidance at a practice level.

As highlighted in the article, TN is a complex condition to diagnose and manage. The following implementation actions are designed to help clinical pharmacists in general practice support patients with TN:

  • educate the MDT—TN is a condition that clinicians may not be familiar with, so it may be useful to run a session in your next clinical meeting to upskill the MDT. Key areas of focus for the session could include the diagnosis and management of TN
  • monitor prescribing—ensure that any treatments apart from carbamazepine or oxcarbazepine have been initiated by a specialist
  • organise investigations—depending on the treatment, ensure that there is a process in place to recall patients who require blood tests, as the majority of treatments for TN require annual FBC, U&E, and LFTs
  • undertake regular review—there is increasing evidence that depression, anxiety, and poor coping mechanisms are common among patients with TN and result in a poor QOL.[A] Therefore, reviewing patients to ensure that their TN is appropriately managed and not impacting their QOL is extremely important
  • utilise the expertise of the MDT—when appropriate, refer patients to other members of the MDT; for example, if a patient is experiencing depression or anxiety, refer them to the mental health nurse
  • signpost sources of patient support—when reviewing patients, it is important topoint them towards local support groups and online information. This information could be uploaded to the practice website by the administration team so that it is easily accessible to patients and members of the MDT.

The i2i Network has a suite of training and implementation resources, both bespoke and free, for clinical pharmacists in general practice, including e-learning, on-demand training delivered by experts covering a range of long-term conditions, and resources to help you put your learning into action. Become a free i2i Network member at:

TN=trigeminal neuralgia; MDT=multidisciplinary team; FBC=full blood count; U&E=urea and electrolytes; LFT=liver function test;QOL=quality of life

[A] Bendtsen L, Zakrzewska J, Abbott J et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol 2019; 26 (6): 831–849.