A little bit about trigeminal neuralgia

Malcolm had pain in the distribution of the trigeminal nerve (usually in the cheek or lower jaw) that was
Severe — described to the GP as electric shock-like, sharp or shooting.
Unilateral — trigeminal neuralgia is bilateral in only 3% of people.
Recurrent — he was experiencing many attacks a day, with a refractory period between each attack.

Provoked by factors such as light touch to the face, eating, talking or exposure to cold air.

These are typical of trigeminal neuralgia – hence why he was managed with Carbemazepine.

Remember, there are other conditions that can lead to compression of the nerve however, such as;
– Tumours
– Multiple sclerosis
– Epidermoid, Dermoid cysts
– Aneurysm

Think of how you would rule out the above differential diagnoses for Malcolm

Also, assess for the presence of red flag symptoms and signs that may suggest he has RED FLAGS, including:

  • Sensory changes.
  • Deafness or other ear problems. 
  • History of skin or oral lesions that could spread perineurally.
  • Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally.
  • Optic neuritis.
  • Family history of multiple sclerosis.

(if he had trigeminal neuralgia and was under 40 years old, this could also be considered as a red flag.)

If there are symptoms that may suggest a serious underlying cause, admit or refer urgently for specialist assessment, depending on clinical judgement.

If there are no red flag symptoms and signs, offer the person carbamazepine. (NICE 2022)

  • Carbamazepine is the only licensed anticonvulsant medication with proven efficacy to treat trigeminal neuralgia.
  • Initiate therapy at 100mg up to twice daily, and titrate in steps of 100–200mg every 2 weeks, until pain has been relieved.
  • In the majority of people a dosage of 200mg three or four times a day is sufficient to prevent paroxysms of pain (maximum dosage 1600 mg daily). Modified release preparations may be useful, particularly if the person experiences breakthrough pain at night.
  • Once the pain is in remission, the dosage should be gradually reduced to the lowest possible maintenance level or the drug can be discontinued until a further attack occurs.

However Malcolm has now developed a rash!!!!