Symptoms of Trigeminal Neuralgia
Trigeminal neuralgia presents with sudden, unilateral, severe, brief stabbing recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve, described as electric shock-like sensations lasting seconds to minutes. 1, 2
Core Pain Characteristics
The hallmark symptom is paroxysmal sharp pain with these defining features:
- Electric shock-like or lancinating quality - brief, stabbing sensations that are abrupt in onset and termination 1, 3, 4
- Duration of seconds to minutes per attack, not continuous pain 2, 5
- Mandatory refractory periods between attacks - patients cannot trigger attacks repeatedly without pain-free intervals 2
- Unilateral distribution following one or more branches of the trigeminal nerve (V1, V2, or V3) 1, 3
Trigger Phenomena
A pathognomonic feature is trigger zones - small facial areas where minimal stimulation precipitates attacks:
- Light touch to the face 3, 6
- Washing the face or brushing teeth 7, 6
- Eating, chewing, or talking 7, 3, 6
- Shaving 6
- Cold wind or breeze across the face 7, 6
These triggers are characteristically innocuous stimuli that would not normally cause pain 4, 5
Classical vs. Type 2 Presentation
Classical trigeminal neuralgia has purely paroxysmal attacks with complete pain-free intervals between episodes 2. However, Type 2 trigeminal neuralgia presents with:
- Prolonged continuous background pain between the characteristic sharp shooting attacks 2
- This continuous pain component suggests more central mechanisms rather than peripheral neurovascular compression 2
Associated Features
- Facial spasms may occur during intense flare-ups (tic douloureux) 3
- Normal neurological examination between painful episodes in classical trigeminal neuralgia 1, 4
- Psychological impact - fear and depression may develop with severe disease 7
- No autonomic features in classical trigeminal neuralgia (no tearing, eye redness, or rhinorrhea) - their presence suggests trigeminal autonomic cephalgias instead 1, 2
Red Flags Suggesting Alternative Diagnoses
The presence of these features should prompt consideration of other conditions:
- Continuous pain without paroxysmal attacks suggests persistent idiopathic facial pain, post-herpetic neuralgia, or atypical odontalgia 1, 2
- Autonomic symptoms (tearing, conjunctival injection, rhinorrhea) indicate trigeminal autonomic cephalgias like SUNCT/SUNA, not true trigeminal neuralgia 1, 2, 7
- Sensory deficits in the trigeminal distribution require urgent imaging to rule out secondary causes like tumors or multiple sclerosis 2
- Bilateral pain is atypical and warrants investigation for alternative diagnoses 3
Clinical Pitfall
Do not diagnose trigeminal neuralgia if the patient describes continuous pain or can trigger attacks repeatedly without pain-free intervals - this should prompt MRI evaluation to rule out secondary causes 2. The ability to have mandatory refractory periods between attacks is essential for the diagnosis 2.