Sharp Intermittent Unilateral Pain Near the Nares
This presentation is most consistent with trigeminal neuralgia affecting the maxillary (V2) division, and you should initiate carbamazepine as first-line treatment while ordering MRI to exclude secondary causes. 1, 2
Key Diagnostic Features
The sharp, intermittent, unilateral nature of this pain strongly suggests trigeminal neuralgia rather than sinusitis or other continuous pain syndromes. 1, 2
Classical trigeminal neuralgia presents with:
- Paroxysmal attacks lasting seconds to minutes (not continuous) 1, 3
- Sharp, shooting, electric shock-like quality 1, 2
- Unilateral distribution following trigeminal nerve branches, most commonly V2 (maxillary) and V3 (mandibular) divisions 1, 2
- Mandatory refractory periods between attacks 1, 3
- Triggers including light touch, washing, cold wind, eating, or brushing teeth 1, 4
Critical Differential Diagnoses to Exclude
Sinusitis presents differently with continuous dull aching pain, purulent rhinorrhea, postnasal drainage, nasal congestion, and symptoms persisting beyond 10-14 days—not sharp intermittent attacks. 1
SUNCT/SUNA (trigeminal autonomic cephalgias) can mimic trigeminal neuralgia but includes autonomic features: tearing, conjunctival injection, rhinorrhea, or facial redness during attacks, with up to 200 attacks daily and no refractory period. 1, 3
Giant cell arteritis (if patient >50 years) causes continuous temporal/jaw pain worsened by chewing, with scalp tenderness, visual disturbances, elevated ESR/CRP, and requires urgent high-dose corticosteroids to prevent blindness. 1, 4
Diagnostic Workup
Order MRI with high-resolution thin-cut sequences through the trigeminal nerve course immediately. 2 This is the gold standard to:
- Evaluate for neurovascular compression at the root entry zone 2, 3
- Exclude secondary causes: multiple sclerosis, tumors, vascular malformations 2, 3
- Use 3D heavily T2-weighted sequences and MRA to characterize vascular compression 2
Physical examination should assess:
- Trigger points by light touch in trigeminal distribution 1, 2
- Sensory changes (rarely present in classical trigeminal neuralgia) 1
- Absence of autonomic features during attacks 3
Treatment Algorithm
Start carbamazepine immediately as the gold standard first-line treatment without waiting for MRI results if clinical presentation is classic. 3, 4
Second-line options if carbamazepine fails or causes intolerable side effects:
- Oxcarbazepine (equally effective with fewer side effects) 3
- Gabapentin combined with ropivacaine 3
- Pregabalin 3, 5
- Lamotrigine 3, 4
- Baclofen 3, 4
Surgical intervention (microvascular decompression or ablative procedures) should be considered when medications fail to control symptoms. 3, 4
Critical Pitfalls to Avoid
Do not treat as sinusitis if pain is intermittent and sharp rather than continuous and dull—antibiotics will not help trigeminal neuralgia. 1
Do not miss temporal arteritis in patients over 50 with any continuous component to pain, jaw claudication, or visual symptoms—this requires immediate corticosteroids. 1, 4
If continuous pain exists between sharp attacks, consider Type 2 trigeminal neuralgia or secondary causes requiring more aggressive MRI evaluation for central lesions. 3
Bilateral symptoms are atypical and warrant expanded differential diagnosis including multiple sclerosis or other systemic conditions. 2