Trigeminal Neuralgia
Trigeminal neuralgia (tic douloureux) is a cranial neuralgia characterized by sudden, severe attacks of electric-shock-like or stabbing pain on one side of the face. In most cases it is caused by a blood vessel compressing the fifth cranial (trigeminal) nerve where it exits the brainstem. Treatment begins with medication; in resistant cases surgical options such as microvascular decompression (MVD) are used.
마지막 업데이트: 2026-06-07
Definition
Trigeminal neuralgia is the most common cranial neuralgia and arises from irritation of the fifth cranial nerve (the trigeminal nerve), which carries sensation from the face. The pain is typically on one side of the face, very severe, comes in attacks lasting from seconds to a few minutes and can be triggered by light stimuli. In the classic (idiopathic) form, the neurological examination is usually normal.
Causes
In most cases of classic trigeminal neuralgia, the cause is pulsatile compression of the nerve by a blood vessel at its root entry zone in the brainstem (most often the superior cerebellar artery; less commonly the AICA or basilar artery). The vessel's pulsation causes chronic irritation and loss of myelin on the nerve, leading to abnormal pain signals. In some cases there are secondary causes: multiple sclerosis, posterior fossa tumours (meningioma, schwannoma, epidermoid cyst), arteriovenous malformation or Chiari malformation. Secondary causes should be investigated particularly in cases that begin before age 40, are bilateral or are accompanied by a neurological deficit.
Symptoms
Pain is usually felt on one side of the face, in the distribution of the maxillary (V2, cheek) or mandibular (V3, jaw/lower face) branches of the trigeminal nerve; involvement of the ophthalmic branch (V1, forehead and around the eye) is less common. Attacks begin suddenly, last from seconds to two minutes and end just as abruptly. Everyday stimuli such as washing the face, brushing the teeth, chewing, talking, light touch or a cold breeze can trigger the pain (trigger zones). Early on there are pain-free periods between attacks; as the disease progresses the attacks may become more frequent and some patients develop a continuous dull ache (atypical form). Fear of eating and talking can lead to social isolation and weight loss.
Diagnosis
Diagnosis is primarily clinical; the characteristic paroxysmal, electric-shock-like pain described by the patient together with trigger factors is diagnostic. High-resolution brain MRI (particularly thin-section sequences such as FIESTA/CISS) can show the neurovascular contact between the nerve and the offending vessel and is valuable for surgical planning. MRI is also needed to exclude secondary causes such as multiple sclerosis plaques, posterior fossa tumours and vascular malformations. The differential diagnosis includes postherpetic neuralgia, dental conditions (tooth abscess, jaw-joint problems), atypical facial pain, migraine and cluster headache.
Medical (Conservative) Treatment
Medication is the first step. Carbamazepine is the most effective first-line agent and controls pain in a substantial proportion of patients; it is started at a low dose and increased gradually. Possible side effects include drowsiness, dizziness, unsteadiness, low sodium (hyponatraemia) and, rarely, serious skin or blood reactions, so treatment is carried out under regular monitoring. In patients who cannot tolerate carbamazepine, oxcarbazepine and, as additional options, baclofen, lamotrigine (especially in multiple-sclerosis-related cases), gabapentin and pregabalin may be used. In resistant cases drugs may be combined.
Surgical and Interventional Treatments
Surgical and interventional methods are considered in patients who do not respond to medication, cannot take medication because of side effects or want a lasting solution. Microvascular decompression (MVD) is a cause-directed surgical treatment for classic trigeminal neuralgia: through a retromastoid craniotomy the vessel compressing the nerve is identified and a soft spacer (for example Teflon) is placed between the nerve and the vessel to relieve the compression. It is performed under general anaesthesia. Stereotactic radiosurgery (Gamma Knife) is an incision-free option used particularly in older patients, those at high surgical risk or those who prefer not to undergo surgery; its effect begins within weeks. Percutaneous procedures (radiofrequency rhizotomy, balloon compression, glycerol injection) are ablative techniques applied to the Gasserian ganglion and are often preferred in older or high-risk patients. Each method has its own success rate, recurrence risk and side-effect profile (for example facial numbness); the choice is individualized.
Prognosis
Trigeminal neuralgia can be effectively controlled with medication in most patients and, in resistant cases, with surgical or interventional methods. Microvascular decompression can provide long-term pain control in suitable patients; however, owing to the nature of the disease, recurrence may occur over time. The choice of treatment is made according to the patient's age, general health, the characteristics of the pain and the imaging findings. Outcomes vary from person to person and cannot be guaranteed in advance.
참고 문헌
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:1857-1870.
- Winn HR, ed. Youmans Neurological Surgery. 6th ed. Saunders; 2011:1777-1800.
- Bendtsen L, Zakrzewska JM, Abbott J, et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019;26(6):831-849.
- Barker FG 2nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med. 1996;334(17):1077-1083.
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