Why Trigeminal Neuralgia Is Frequently Misdiagnosed In Its Early Stages

Facial pain can have many different causes, and identifying the underlying condition is not always straightforward. Dental problems, sinus conditions, temporomandibular disorders and neurological conditions can all produce discomfort around the face, jaw or teeth.

For people with trigeminal neuralgia, this overlap can sometimes make diagnosis challenging, particularly when symptoms first appear.

Recognising the characteristic pattern of trigeminal neuralgia and understanding when specialist neurological assessment may be appropriate can help patients reach an accurate diagnosis.

What is trigeminal neuralgia?

Trigeminal neuralgia is a neurological disorder affecting the trigeminal nerve, the fifth cranial nerve. This nerve carries sensory information from much of the face to the brain and also contributes to the muscles involved in chewing.

Trigeminal neuralgia typically causes recurrent episodes of sudden facial pain. Patients may describe the sensation as sharp, stabbing or similar to an electric shock.

Pain can affect areas including the:

• Jaw
• Cheek
• Teeth
• Lips
• Nose
• Forehead

Symptoms most commonly affect one side of the face and may be triggered by activities such as speaking, eating, brushing the teeth or lightly touching the skin.

Why can trigeminal neuralgia be misdiagnosed?

One of the main challenges is that the trigeminal nerve supplies sensation to areas that overlap with structures commonly associated with dental and ear, nose and throat conditions.

For example, pain affecting the jaw or teeth may initially appear to have a dental cause. A patient may therefore visit a dentist before a neurological explanation is considered.

Similarly, facial pain around the nose or forehead can sometimes be confused with sinus-related symptoms.

This does not mean that an initial assessment is inappropriate. Dental and other common causes should be considered and excluded where relevant. However, persistent or unusual facial pain may require further neurological investigation if no clear explanation is identified.

Facial pain that may point towards trigeminal neuralgia

The pattern of pain can provide important diagnostic information.

Trigeminal neuralgia is often characterised by:

• Sudden attacks of severe facial pain
• Short episodes that may occur repeatedly
• Pain affecting one side of the face
• Electric shock-like or stabbing sensations
• Pain triggered by otherwise harmless activities
• Periods between attacks when symptoms may be less noticeable

Triggers can include eating, talking, shaving, brushing the teeth or touching the face.

However, not every patient has exactly the same symptoms. This is why diagnosis should be based on a detailed clinical assessment rather than a single symptom.

When dental investigations do not explain the pain

Dental conditions are a common consideration when someone experiences pain around the teeth or jaw. Dentists may appropriately investigate problems such as tooth decay, infection or other oral conditions.

If dental examinations and treatments do not explain persistent or recurrent facial pain, however, it may be appropriate to consider other causes.

A neurological assessment can help determine whether the symptoms could be associated with the trigeminal nerve. This is particularly relevant when the pain has a distinctive pattern, occurs in sudden attacks or is triggered by light touch or everyday facial movements.

The importance of specialist neurological assessment

A specialist assessment usually begins with a detailed discussion about the patient's symptoms.

The clinician may ask:

• Where exactly does the pain occur?
• How long does each episode last?
• How frequently does it happen?
• What triggers the pain?
• Does it affect one or both sides of the face?
• Are there periods without symptoms?
• Have dental or other investigations already been carried out?

A neurological examination may then be performed to assess facial sensation and cranial nerve function. This information can help distinguish trigeminal neuralgia from other causes of facial pain.

Different types of trigeminal neuralgia

Specialists may classify trigeminal neuralgia according to its underlying cause.

• Classical trigeminal neuralgia is generally associated with compression of the trigeminal nerve by a blood vessel near its connection with the brainstem.
• Secondary trigeminal neuralgia occurs when another neurological condition affects the nerve. Potential causes include multiple sclerosis or a structural abnormality.
• Idiopathic trigeminal neuralgia is diagnosed when the characteristic symptoms are present but investigations do not identify a specific underlying cause.

Determining which form is present can help guide further treatment discussions.

For patients experiencing unexplained facial pain, recognising the distinctive features of trigeminal neuralgia can be an important first step towards receiving the right diagnosis and specialist care.

Explore Queen Square Neuroscience Health Centre's specialist services for trigeminal neuralgia, including advanced neurological assessment, imaging, second opinions and Gamma Knife treatment where appropriate.