In a woman over 50 with sudden brief electric‑shock facial pain in one or more trigeminal branches triggered by chewing, speaking, or touching, how should I evaluate and manage suspected trigeminal neuralgia?

Evaluation and Management of Trigeminal Neuralgia in Women Over 50

Diagnostic Confirmation

Establish the diagnosis clinically by confirming unilateral paroxysmal pain lasting seconds to minutes with mandatory pain-free refractory periods between attacks, sharp electric shock-like quality in V2/V3 distribution, and trigger-zone sensitivity to light touch. 1

Key Clinical Features to Elicit

• Pain character: Sharp, shooting, electric shock-like attacks lasting 2 seconds to several minutes, not continuous pain 2, 1
• Mandatory refractory period: Pain-free intervals between attacks distinguish this from other facial pain syndromes; if the patient can trigger attacks repeatedly without pain-free intervals, consider alternative diagnoses 1, 3
• Distribution: Most commonly affects maxillary (V2) and mandibular (V3) branches unilaterally 1, 3
• Triggers: Light touch, washing face, cold wind, eating, tooth brushing—normally innocuous stimuli 2, 1
• Neurological examination: Should be completely normal between attacks in classical trigeminal neuralgia 3, 4

Critical Red Flags in Women Over 50

Giant cell arteritis must be urgently excluded in this age group, as it presents with continuous dull aching temporal or jaw pain worsened by chewing, accompanied by scalp tenderness, elevated ESR/CRP, visual disturbances, fever, and diminished temporal pulse—requiring immediate high-dose corticosteroids (minimum 40 mg daily) to prevent blindness. 2, 1

Differential Diagnoses to Exclude

• Trigeminal autonomic cephalgias (SUNCT/SUNA): Up to 200 attacks daily without refractory periods, accompanied by tearing, conjunctival injection, rhinorrhea, facial redness 2, 1, 3
• Post-herpetic neuralgia: Continuous burning pain at site of prior herpes zoster eruption with allodynia, not paroxysmal attacks 1, 3
• Glossopharyngeal neuralgia: Deep ear/back of tongue pain triggered by swallowing, may cause syncope 2, 3
• Atypical odontalgia: Continuous aching pain localized to tooth-bearing area 2

Imaging Evaluation

Obtain brain MRI with and without contrast using high-resolution thin-cut sequences through the trigeminal nerve in all suspected cases. 3, 4, 5

Imaging Protocol Specifics

• 3D heavily T2-weighted sequences combined with MRA to identify neurovascular compression (83-100% congruence with surgical findings) 1, 3
• Pre- and post-contrast imaging to identify secondary causes: multiple sclerosis plaques, tumors, or other structural lesions 1, 3
• Include pituitary fossa views if SUNCT/SUNA is suspected 1
• Assess for neurovascular compression at the trigeminal root entry zone, which is the anatomic abnormality in classical trigeminal neuralgia 1, 4, 6

Pharmacological Management

Start carbamazepine 200 mg at bedtime, then gradually increase by 200 mg every 7 days to a target dose of 400-1200 mg daily divided into 2-3 doses, taken routinely on a scheduled basis—not as-needed. 7

First-Line Treatment Evidence

• Carbamazepine is the gold standard with Level A evidence from four placebo-controlled trials showing 70% of patients achieve partial or complete pain relief 3, 7, 4, 5
• Oxcarbazepine is equally effective with fewer side effects and serves as an alternative first-line agent 1, 3, 8
• Monitor for dose-dependent side effects: drowsiness, headache, dizziness that may limit escalation 3, 6
• Continuous scheduled dosing is mandatory to maintain therapeutic plasma concentrations and prevent attacks from occurring 7

Second-Line Options When First-Line Fails

If carbamazepine/oxcarbazepine are ineffective or not tolerated, add or switch to lamotrigine, baclofen, gabapentin combined with ropivacaine, or pregabalin. 1, 3, 8

• These agents also require continuous daily administration, not as-needed dosing 7
• Combination therapy with carbamazepine may provide synergistic benefit 8

Surgical Referral

Obtain neurosurgical consultation early when medications become ineffective or intolerable. 3

Surgical Decision Algorithm

• Microvascular decompression (MVD) is the preferred surgical option for patients with documented neurovascular compression on MRI without significant comorbidities 3, 5
• MVD efficacy: 70% pain-free at 10 years, but carries 2-4% risk of hearing loss and 0.4% mortality 3
• Percutaneous radiofrequency thermocoagulation is recommended for elderly patients or those with major comorbidities 5
• Stereotactic radiosurgery typically provides pain relief within one month but can take up to six months 1

Common Pitfalls to Avoid

• Do not diagnose trigeminal neuralgia if pain is continuous—this suggests Type 2 trigeminal neuralgia, post-traumatic neuropathy, or alternative diagnosis requiring MRI to rule out secondary causes 1
• Do not use carbamazepine as-needed—scheduled daily dosing is essential for efficacy 7
• Do not delay imaging—MRI is mandatory in all cases to exclude tumors, MS, and determine surgical candidacy 3, 4
• Do not miss giant cell arteritis in patients over 50 with any atypical features, as this requires urgent treatment to prevent blindness 2, 1