Introduction: When he came to see me holding his imaging scans, he looked completely confused: the pain was excruciating, so why did every test come back normal? This is one of the most common frustrations experienced by patients with trigeminal neuralgia. The diagnosis of this condition is established not primarily through imaging, but through clinical history-taking.

One patient left a particularly deep impression on me. He was a man in his fifties who had suffered from right-sided facial pain for nearly a year. At first, he believed the problem was dental in origin. He visited two dental clinics and a public hospital, underwent extraction of two teeth, yet the pain persisted. Later, he underwent both CT and MRI examinations, but the reports stated: “No significant intracranial abnormality detected.” When he finally came to see me carrying those scans, he looked bewildered: the pain was severe, yet every examination appeared normal.

This is, in fact, one of the most common frustrations surrounding trigeminal neuralgia. The diagnosis of this disorder does not primarily depend on imaging findings, but rather on careful clinical questioning.

The role of imaging studies is mainly to exclude other conditions—such as intracranial tumors or large vascular structures compressing the trigeminal nerve. If imaging clearly demonstrates a space-occupying lesion or vascular compression, the diagnostic pathway changes entirely. However, in the majority of patients with trigeminal neuralgia, imaging studies appear essentially normal. In these situations, an experienced physician relies on the patient’s clinical history

What should be asked? How should the questioning proceed? I usually focus on four key aspects.

First, whether the pain occurs in sudden attacks. Trigeminal neuralgia has a very characteristic presentation: during an episode, the pain feels like an electric shock, lasting only a few seconds before disappearing completely, with entirely normal intervals in between. This differs from toothache, which is typically a continuous dull pain. Trigeminal neuralgia is instead characterized by abrupt, paroxysmal pain. One patient described it to me as “feeling like being stabbed in the face.” Oddly enough, after the attack ended, he felt relieved simply because he knew “that wave had passed.” This abrupt onset and sudden cessation are highly important diagnostic clues.

Second, the severity of the pain. Many patients rate it above 8 out of 10, and some describe it as even more painful than childbirth. One of the most extreme descriptions I have heard was: “It hurt so badly that I wanted to cut off half my face.” This is not an ordinary headache or dental pain—it is an incapacitating level of pain that can profoundly disrupt daily life. Many patients become afraid to wash their face, brush their teeth, smile, or even speak, because they fear triggering another attack.

Third, whether there is a “trigger zone” on the face. Patients with trigeminal neuralgia often have a specific area that provokes severe pain when lightly touched, known clinically as a trigger point or trigger zone. Common locations include the corner of the mouth, the sides of the nostrils, or the chin. One elderly woman told me she had not chewed food on the right side of her mouth for three months because every attempt caused pain severe enough to bring tears to her eyes. The presence of a trigger zone is a classic manifestation of abnormal discharge of trigeminal sensory fibers within trigeminal sensory fibers.

Fourth, whether medication is effective. Carbamazepine is considered the first-line pharmacological treatment for trigeminal neuralgia, and I usually ask patients to try it for a period of time. If the pain decreases significantly within several days, the response serves not only as treatment but also as an important diagnostic clue. A favorable response to carbamazepine strongly supports the diagnosis of trigeminal neuralgia. Of course, not every patient responds to the medication, and its effectiveness may diminish over time, but short-term responsiveness remains clinically meaningful.

By integrating all of this information, a physician familiar with the disorder can usually make the diagnosis with reasonable confidence.

Of course, establishing the diagnosis is only the first step. Once trigeminal neuralgia is confirmed, the next question becomes how to treat it—whether with medication or surgery, and how factors such as age and overall physical condition should influence management decisions. But none of this can proceed until the diagnosis itself is clarified. Many patients spend months moving between different specialties—dentistry, otolaryngology, and neurology—without encountering the right specialist. In clinical practice, it is not uncommon for trigeminal neuralgia to be mistaken for dental pain, migraine, or even cervical spine disease.

If you or an elderly family member is currently suffering from recurrent episodes of severe facial pain, it may be helpful to consider the following questions: Does the pain feel like an electric shock? Does each episode last only a short time? Is there a specific area of the face that cannot be touched? Does carbamazepine provide relief? If these features are present, consultation with a neurosurgeon or pain specialist is strongly recommended for a professional evaluation.

Reference: https://www.incsg.com/sanchaqiaoliu/8160.html