The names used to differentiate types of TN may vary from doctor to doctor. In order to provide one internationally accepted naming standard, below is the International Classification of Headache Disorders 3rd Edition. The following classifications are based on a consensus between the International Headache Society (IHS) and the International Association for the Study of Pain (IASP).

Classical trigeminal neuralgia (also called TN1/Typical TN)

Description: Classical trigeminal neuralgia without persistent background facial pain.

An artery or vein compressing the trigeminal nerve causes the intense pain of TN. This type of TN is sometimes referred to as TN1, Type 1, or Classic TN. Classical TN is characterized by sharp, stabbing, paroxysms of severe pain, typically lasting a fraction of a second to two minutes. The paroxysms are very severe in intensity, usually having a trigger zone or an action that will trigger or activate the shock-like jolt. The pain is almost always unilateral (on one side) and located in the second (midface) or third (jaw) trigeminal nerve branches. Pain rarely is seen in the first division (forehead).

The cause of Classical TN is typically nerve compression by a vessel, usually the superior cerebellar artery on the trigeminal nerve root as it leaves the brain stem or pons. Classical trigeminal neuralgia with purely paroxysmal pain is also marked by periods of complete pain-free remissions.

Classical TN with concomitant continuous pain (also called Atypical TN/ATN/TN 2)

Description: Classical trigeminal neuralgia with persistent background facial pain. People with atypical TN experience a persistent dull ache or burning sensation in one part of the face. However, episodes of sharp pain can complicate atypical TN. There is often not a specific trigger point for the pain; the pain may grow worse over time.

Secondary trigeminal neuralgia

Description: Trigeminal neuralgia caused by an underlying disease.

Idiopathic trigeminal neuralgia

Description: Trigeminal neuralgia with neither electrophysiological tests nor MRI showing significant abnormalities.

Painful trigeminal neuropathy

Description: Facial pain in the distribution(s) of one or more branches of the trigeminal nerve caused by another disorder and indicative of neural damage (including herpes zoster, postherpetic neuralgia, and post-traumatic neuropathy).

The medicines doctors typically prescribe to treat trigeminal neuralgia were originally developed to treat epilepsy. However, this class of medications, called anticonvulsants, has been found to be quite effective in treating nerve pain, including trigeminal neuralgia. A positive response to these drugs might signal to your doctor that classical TN is an accurate diagnosis. Carbamazepine and oxcarbazepine are frequency-dependent sodium channel blockers that reduce pain in approximately 90% of people with TN. These drugs are not always well tolerated and need to be titrated (increasing or lowering doses) carefully.

Where there is a continuous or longer lasting dull, burning, aching background pain, the addition of a tricyclic antidepressant such as nortriptyline, in doses around 50-100 mg, at bedtime, may be helpful. Other anticonvulsants such as levetiracetam and zonisamide may be useful but have not been studied in placebo-controlled trials. Baclofen is a muscle relaxant that is very effective in trigeminal neuralgia in doses between 5 and 80 mg daily. Sedation is the most significant side effect. Phenytoin may be used as an alternative in doses of 100 – 300 mg per day.

Stimulus-provoked pain is typical of TN. Triggered pain is one of the signs to your doctor to indicate a diagnosis of TN. In most people, TN pain is triggered by ‘innocuous mechanical stimuli’- that would not hurt someone without TN. Subtle stimuli can be a breeze or light touch of the face. Touch plus facial movements can also trigger pain. Movement alone can also be enough to provoke TN pain. The location of your pain may be different from the location that was stimulated. You may also experience a refractory period of several seconds or minutes after a pain attack when a new attack cannot be provoked.

Attacks of TN may be triggered by:

• Touching the skin lightly (reported in 65%)
• Washing
• Shaving
• Brushing teeth
• Blowing the nose
• Drinking hot or cold beverages
• Encountering a light breeze
• Applying makeup
• Smiling
• Talking (reported in 76%)
• Chewing (reported in 74%)
• Cold (reported in 48%)

There are also reports of pain triggered by sweet, salty, or spicy foods, which also might indicate a dental issue. Your trigger may not be listed here, but that does not mean that you do not have TN.

TN can be very difficult to diagnose, because there are no specific diagnostic tests and symptoms are very similar to other facial pain disorders. Trigeminal neuropathic pain is almost always diagnosed by your description of your symptoms. The Burchiel Questionnaire or the McGill Pain Questionnaire may help your doctors determine how to treat you for your pain.

Your doctor will likely order an MRI scan when TN is suspected in order to rule out multiple sclerosis or a tumor and to look for an offending blood vessel that is causing the pain. High-resolution, thin-slice or three-dimensional MRIs have the ability to show fine trigeminal nerve compression.

Commercial names for high-resolution images are:

• SSFP: Steady-State Free Precession
• GE FIESTA: Fast Imaging Employing Steady-state Acquisition
• Siemens FISP: Fast Imaging with Steady-state Precession
• Philips FFE: Fast Field Echo, b-FEE: Balanced Fast Field Echo

It is not likely that your pain will resolve on its own. TN pain usually occurs in cycles, sometimes with periods of remission for weeks, months or even years. Over time, attacks of pain may come more frequently and be increasingly severe

AD can be a side effect of surgery involving any part of the trigeminal system. There are several theories about what causes AD.

• Theory 1: The touch-carrying nerve fibers are injured by surgery, while little or no damage occurs to pain-carrying fibers.
• Theory 2: Surgical injury may also prevent nerve fibers from overlapping as they normally should, resulting in distorted signals being sent to the brain.
• Theory 3: AD pain is much like phantom limb pain, but is occurring to an amputated trigeminal nerve branch instead of an arm or leg. After surgery, when these pain signals suddenly stop, the brain may deal with this loss of input by remembering and replaying old pain signals.

Medications

• Muscle relaxants (Baclofen, Zanaflex)
• Antidepressants like amitriptyline (Elavil), nortriptyline (Pamelor), clonidine (Catapres), paroxetine (Paxil)
• Anticonvulsants such as TN- carbamazepine (Tegretol, Carbatrol), oxcarbazepine (Trileptal), gabapentin (Neurontin), clonazepam (Klonopin), valproate (Depakote), topiramate (Topamax), phenytoin (Dilantin)
• Topical anesthetic (EMLA)
• Topical ointments (Zostrix, Capsaicin-P)
• Anesthetic Injections (lidocaine), opioids
• Oral Morphine drugs (oxycontin)

Complementary health approaches

• Acupuncture
• Upper cervical chiropractic
• Nutrition therapy
• Hot and cold compresses
• Biofeedback
• Electrical stimulation (TENS, SCENAR)
• Medical treatment
• Anesthetic injections (nerve blocks)
• Smiling
• Motor cortex stimulation (an implanted electrode gives constant electrical stimulation)
• Drez procedure

As medical science better understands the brain, surgeons also are looking into the newer field of stimulating or selectively disabling parts of the brain that process pain signals.

Undergoing an MRI during diagnostic testing should show the existence of a tumor and would provide you and your doctor information about how to proceed with treatment. Neurologists and neurosurgeons understand when and how to image the trigeminal nerve whenever the diagnosis of trigeminal neuralgia is considered.

In a series of 1,185 patients who underwent surgery for TN over a period of two decades by Dr. Peter Jannetta, less than 1%, or eight patients, had an associated acoustic neuroma (AN) tumor. In a series of 2,000 patients over one decade operated on by Dr. John Tew, only four patients had an associated AN. The patients in Dr. Tew’s series had numbness in their faces caused by the tumor, and one had burning pain, not the typical stabbing pain associated with TN. These observations may indicate what treatment is likely to be more effective.

Upon review of his treatment of his eight patients with AN, Dr. Jannetta concluded that the cause of their stabbing pain was the presence of an artery that had been pushed towards the trigeminal nerve by the expanding AN. It was not the tumor causing the neuropathic facial pain; rather, it was the compression of the nerve by the force of arterial pulsations. To cause TN, an AN has to grow large enough to come into contact with the trigeminal nerve.

If a tumor is compressing your trigeminal nerve, the goal of the surgery is to move that rtery off the nerve and maintain that separation with a small cushion- the same goal as an MVD surgery. The goal of radiation is to prevent tumor growth, not to make the tumor shrink or disappear; therefore, TN caused by a tumor will likely not be relieved. If the target is the trigeminal nerve, radiation may be an option.

There are neurosurgeons experienced treating tumors and trigeminal neuropathic pain who can discuss with you the options for treatment and help you to decide what the best one is for you.

The burning mouth sensation is typically felt on the tip, sides, and/or top of the tongue, but can also occur on the roof of the mouth, and inside the area of the lips. You may also experience the sensation on your gums and/or inside of your cheeks. The burning can be in one or many of these areas at the same time, and can start suddenly or increase in intensity over time. The sensation may be constant or intermittent (come and go).

BMS can be quite uncomfortable and disturbing, but it is a benign condition- it does not endanger your health. The feeling is usually chronic, lasting over a period of weeks, months, or longer. BMS might follow a pattern for you- for example, it might start mildly in the morning, increasing in intensity during the day. 

Other symptoms may include:

• Dry mouth, feeling of thirst
• Changes in taste- bitter or metallic taste in your mouth
• Numbness in your mouth
• People with BMS sometimes also report headache, fatigue, pain in other parts of the body, tinnitus (noise or ringing in the ears), and anxiety. 

There may or may not be an underlying cause for your BMS. In attempting to get a diagnosis and treatment to relieve BMS, many people visit their dentist, general practitioner, dermatologist, ENT and other medical specialists. Your doctor will likely attempt to rule out underlying conditions such as: 

• Vitamin deficiency, particularly vitamin B
• Anemia 
• Type 2 diabetes 
• Medication side effects 
• Allergies 
• Oral yeast infection (thrush) 
• Reflux 
• Dental issues

In the absence of an underlying cause, research suggests that BMS can be a neuropathic pain syndrome, caused by malfunctioning nerves and may be due to injury of the trigeminal nerve, or nerve fibers in the tongue. Psychiatric disorders such as depression and PTSD may be linked to BMS. TMD, chronic fatigue syndrome, and fibromyalgia may be contributing factors. 

Your doctor will examine you and listen to your explanation of your symptoms and history. You may have tests such as blood work, oral cultures, allergy testing or tissue biopsy to rule out underlying conditions. Your doctor may refer you to a dental expert if BMS is diagnosed. 

Treatment for BMS aims to lessen your symptoms. From 50% to 66% of people with BMS will experience some degree of improvement with treatment over a few weeks or months. You may have to try a number of therapies to find the best one or combination for you. Cognitive behavior interventions such as cognitive behavioral therapy can be successful at helping you minimize your discomfort with BMS. There are also at-home or homeopathic treatments you may try- remember to check with your doctor before you do. 

Topical therapies, such as lidocaine gel or capsaicin cream 

You may determine if certain foods or products trigger your BMS. If so, you can minimize or eliminate your exposure to them. Some common BMS triggers are:

• spicy foods
• hot food
• acidic food
• tobacco
• mouthwash containing alcohol

Diagnosis for GPN is made through your explanation of your symptoms and an examination by your doctor. Because GPN can appear similar to trigeminal neuralgia, it is important for your doctor to exclude TN and other causes of pain due to inflammation or growths. Your doctor will also map out your pain to understand if it is typical GPN or involves other cranial nerves. Laboratory tests may be given to rule out underlying disease. MRI, MRA, and other imaging tests of the head or neck may be used to rule out nerve compression or tumors.

Most cases of GPN happen spontaneously or no cause is found. In some cases, it is caused by compression of the nerve by tumors, malformations, vascular compression, multiple sclerosis (MS), infection, or trauma.

Your doctor will perform an examination of your head and neck, ask you to explain your symptoms and history, and order tests, including an MRI to rule out underlying causes such as trigeminal neuralgia, tumor or underlying disease.

• Medications including anti-seizure drugs such as carbamazepine, gabapentin, and pregabalin
• Vitamin B12
• Glossopharyngeal nerve block, which may also confirm a GPN diagnosis if successful
• Surgery, including microvascular decompression (MVD) and rhizotomy
• Gamma Knife (radiation) surgery

In MS, damage to the myelin coating around the nerve fibers in the central nervous system (CNS) and to the nerve fibers themselves interferes with the transmission of nerve signals between the brain, spinal cord and the rest of the body. Disrupted nerve signals cause the symptoms of MS, which vary from one person to another and over time for any given individual, depending on where and when the damage occurs.

Facial pain occurs in 1.9-6% of patients diagnosed with multiple sclerosis. In a small percentage of patients, it may be the only presenting symptom. For patients with an established diagnosis of MS, trigeminal neuralgia is the most common associated symptom. When trigeminal neuralgia (TN) is caused by MS, it is referred to as secondary trigeminal neuralgia- there is an underlying disease causing your facial pain. Trigeminal neuralgia almost always occurs on one side of the face, although in MS patients, it occurs more frequently on both sides, in about 18 percent of cases.

Facial Pain in MS is typically:

• Sudden, intense, sharp, superficial, stabbing
• Lasting from a second to several minute
• May involve more than one part of the face on the same side
• Surgery, including microvascular decompression (MVD) and rhizotomy
• Brought on by a trigger
• May be bilateral (on both sides)

Surgical therapy is controversial. The early reports found radiofrequency rhizotomy to be useful for the initial treatment of pain; however, the recurrence rate of pain is higher and the duration of pain relief may be shorter. Radiofrequency treatment for TN-MS is still the procedure of choice for most patients. Glycerol treatment may also be an option. Some numbness needs to be produced for the best and longest-lasting results. Studies of MVD surgery for patients with MS have shown a pattern: good initial pain relief with less sustained results. The majority of the FPA Medical Advisory board do not favor MVD for these patients. At the current time, radiofrequency and glycerol procedures have the clearest indications, with more information needed over time for the remaining choices.

People with MS can experience a wide variety of symptoms and signs, including numbness, parenthesis, pain, weakness, spasticity, fatigue, vertigo, visual difficulties, gait dysfunction, bladder disturbances and cognitive changes. As pain can be present in other sites in the course of MS, there are several reports of gabapentin, and lamotrigine being useful for pain in MS. In general, patients with MS are less likely to tolerate the medications used for TN.

For more information on MS, visit the National MS Society.

Occipital neuralgia (ON) is a relatively rare condition that manifests itself with pain on one or both sides of the head. Unilateral ON (on one side) is seen in 85% of cases. The pain usually starts in the back of the head and travels higher and toward the front, eventually  reaching the very top of the head (the vertex). It is described as shooting, electric-shock like, or stabbing in nature (and this in medical terminology is referred to as paroxysmal lancinating pain). Very often there is also a dull aching pain between the shooting attacks located in the same general area. 

The duration of attacks lasting from few seconds to few minutes, the severe intensity of pain, presence of either tenderness over the course of the occipital nerves or trigger points within the occipital area, as well as pain or discomfort observed with innocuous stimulation of the scalp or hair (such as hair brushing or shampooing that would not normally cause pain) are all characteristic features of ON. 

Another classical feature that helps in making proper diagnosis is the improvement or disappearance of pain in response to numbing the nerve with an injection of local anesthetic in the vicinity of the nerve in question (nerve block). Such blocks are used to both diagnose and treat ON as the pain relief from a single injection may last quite long. In order to make diagnosis of ON, the patient is asked or tested for all of the above-mentioned above features, keeping in mind that other conditions that present with pain in the occipital region (migraines, cluster headaches and hemicranias, tension headaches, cervicogenic headaches that arise from dysfunction of the joints within the spinal column and neighboring cervical muscles, etc.) have to be ruled out first.

Very frequently, in order to rule out associated anatomical pathology, it is necessary to perform appropriate imaging of the head and neck – this would usually include MRI of the brain and the cervical spine. The imaging would allow detection of Chiari malformations, cervical spondylosis, vascular, and neoplastic conditions; in most ON cases the MRI studies are read as normal or almost normal.

Interestingly enough, the exact source of pain in ON remains unknown – it is commonly accepted as a neuropathic pain condition, meaning that the underlying process is the malfunction of the nervous system. The occipital nerves, the culprit of ON, appear to be hyperactive and irritated but the reason for this irritation is often unclear. Multiple existing theories postulate compression or entrapment of the nerve or nerves anywhere along their course in the patient’s neck and head, but there is no consensus or a universally accepted understanding of the underlying pathology.

As with all chronic pain syndromes, the treatment of ON is administered in systematic fashion – starting from conservative measures: medications, interventions, and, ultimately, surgery. As the natural course of ON may be self-limiting and the pain may improve over time, it may be prudent to avoid risky interventions early on in the course of the disease, but medically-refractory cases (those not yielding to treatment) are often considered for invasive treatments as the pain may become disabling and making risks of interventional or surgical treatment justified.

The common initial treatments include application of cold and warm packs, massage, and physical therapy. Rest also frequently reduces the pain. 

Symptoms are usually limited to the area of skin where the shingles outbreak first occurred and may include:

• Occasional sharp burning, shooting, jabbing pain
• Constant burning, throbbing, or aching pain
• Extreme sensitivity to touch
• Extreme sensitivity to temperature change
• Itching
• Numbness
• Headaches
• Pain that lasts longer than three months 

Medication can help to alleviate the pain of PHN,  including anti-seizure medications, antiviral agents, antidepressants, and opioid pain relievers. The pain of PHN can be lessened with anticonvulsants, because they are effective at calming nerve impulses and stabilizing abnormal electrical activity in the nervous system caused by injured nerves. Gabapentin, or Neurontin, and pregabalin, also known as Lyrica, are commonly prescribed to treat this type of pain. Topical patches containing lidocaine, or other pain relievers, are also very effective. 

Temporomandibular disorders (TMD) are a complex and poorly understood set of conditions characterized by pain in the jaw joint and surrounding tissues and limitation in jaw movements. Injuries and other conditions that routinely affect other joints in the body, such as arthritis, also affect the Temporomandibular Joint. One or both joints may be involved and, depending on the severity, can affect a person’s ability to speak, chew, swallow, make facial expressions, and even breathe. 

The exact cause of a person’s TMD is often difficult to determine. Your pain may be due to a combination of factors, such as genetics, arthritis or jaw injury. Some people who have jaw pain also tend to clench or grind their teeth (bruxism), although many people habitually clench or grind their teeth and never develop TMD. 

In most cases, the pain and discomfort associated with TMD is temporary and can be relieved with self-managed care or nonsurgical treatments. Surgery is typically a last resort after conservative measures have failed, but some people with TMD may benefit from surgical treatments. 

The pain of TMD is often described as a dull, aching pain, which comes and goes in the jaw joint and nearby areas. However, some people report no pain but still have problems moving their jaws.

Symptoms may include the following: 

• pain in the jaw muscles 
• pain in the neck and shoulders 
• chronic headaches 
• jaw muscle stiffness 
• limited movement or locking of the jaw 
• ear pain, pressure, fullness, ringing in the ears (tinnitus) 
• painful clicking, popping or grating in the jaw joint when opening or closing the mouth 
• a bite that feels “off” 
• dizziness 
• vision problems 

Most people with TMD have relatively mild or periodic symptoms which may improve on their own within weeks or months with simple home therapy. Self-care practices, such as eating soft foods, applying ice or moist heat, and avoiding extreme jaw movements (such as wide yawning, loud singing, and gum chewing) are helpful in easing symptoms. According to the NIH, because more studies are needed on the safety and effectiveness of most treatments for jaw joint and muscle disorders, experts strongly recommend using the most conservative, reversible treatments possible. 

Conservative treatments do not invade the tissues of the face, jaw, or joint, or involve surgery. Reversible treatments do not cause permanent changes in the structure or position of the jaw or teeth. Even when TM disorders have become persistent, most patients still do not need aggressive types of treatment.

For more information about TMD, contact the TMJ Association.  

With atypical odontalgia, the pain is described as a constant throbbing or aching in a tooth, teeth, or extraction site that is persistent and unremitting, and which is not significantly affected by exposure to hot or cold food or drink, or by chewing or biting. The pain may or may not be relieved by the injection of local anesthetic.  The intensity of the pain can vary from very mild to very severe. 

There is typically no identifiable cause to explain the pain and it often follows or is associated with a history of some type of dental procedure such as having a root canal or tooth extraction. On occasion, the pain can occur without any reason. The pain is felt in a tooth or teeth and persists in spite of treatment aimed to relieve the pain such as a filling, a root canal, or even an extraction. This often presents a frustrating and confusing situation for both the patient and the dentist, and can lead to more and more dental treatment, none of which is effective at relieving the pain. 

The diagnosis of atypical odontalgia is made after a thorough history, clinical examination, and radiographic assessment fail to identify a cause for the pain. Once the diagnosis is made, medications can be used in an effort to reduce the level of pain. 

The cause of atypical odontalgia is not known, and therefore, some clinicians refer to the pain as “idiopathic”. In all likelihood, it is probably due to a variety of factors which may include genetic predisposition, age, and sex. It is more common in women than in men, and is found most often in the middle-aged to older age group. Some studies have found an association between atypical odontalgia and depression and anxiety, however, the significance of this association is unclear. The actual pathologic mechanism seems to be dysfunction or “short-circuiting” of the nerves that carry pain sensations from the teeth and jaws that is triggered by some type of dental or oral manipulation. Areas of the brain that process pain signals appear to undergo molecular and biochemical changes that result in a persistent sensation of pain in the absence of an identifiable cause of the pain. 

Atypical odontalgia is treated by using a variety of medications. Many different medications have been used to treat this condition; however, the tricyclic antidepressants are used most frequently. In addition to the tricyclics, other drugs used to treat chronic pain conditions, such as gabapentin, baclofen, and duloxetine may be prescribed. Generally, treatment is successful in reducing the pain but not eliminating it completely. 

Since the exact cause of this problem is not known, it is difficult to say whether this is a permanent condition. There are cases in which the pain goes away spontaneously as well as cases in which the pain gradually subsides and disappears after prolonged treatment with medications. There are many cases however, that persist and require the continued use of medications. Diagnosis and treatment are best done by a dentist with advanced training and familiarity with the problem, such as a specialist in oral medicine or orofacial pain. 

Glossopharyngeal neuralgia (GPN or GN) is a relatively rare condition, occurring in less than one person in 100,000. The glossopharyngeal nerve is the 9th cranial nerve. It is responsible for feeling in the tongue and throat and movements such as swallowing and the gag reflex, along with others. “Glosso-” means related to the tongue; “pharyngeal” means related to the pharynx, or throat. The pain of GPN is typically severe, brief, sudden, and recurrent pain in the ear, base of the tongue, tonsils or beneath the angle of the jaw. Read more

Trigeminal neuralgia episodes may start as short, mild attacks and progress and cause longer, more-frequent bouts of searing pain. TN pain is described as sudden, intense, “stabbing” or “shock-like”. This pain can occur almost anywhere between the jaw and forehead, including inside the mouth. This pain is usually only on one side of the face, and can include facial twitching (hence, the term ‘tic’). A constant aching, burning feeling that may also occur before evolving into the spasm-like pain. Many people report that their TN attacks become more intense and frequent over time, sometimes with pain-free periods in between. TN is often confused with dental pain. Read more

Burning mouth syndrome (BMS), also known as glossodynia, is a relatively rare condition that causes a burning sensation in your mouth with no obvious cause. This feeling is often compared to taking a large gulp of hot soup or coffee; it may also feel boiling, scorching, dry, tingling, rough/sandy, or stinging. Read more