One of the most severe pains in medicine, and one of the most treatable once correctly identified.
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Trigeminal neuralgia is sudden, severe, electric-shock-like pain in one side of the face. Attacks last seconds to a couple of minutes, and they can come dozens of times a day. It is widely regarded as one of the most severe pains in medicine.
The most useful thing on this page is a warning about what goes wrong: people lose healthy teeth to this. The pain sits in the jaw or the cheek, it feels exactly like a dental problem, and the usual path is a filling, then a root canal, then an extraction — none of which helps, because the problem was never in the tooth. If dental treatment has not touched the pain, that itself is a strong clue.
The second thing is what actually works. Paracetamol, ibuprofen and opioids do essentially nothing for this pain — that is not a matter of dose, it is the wrong class of drug entirely. Carbamazepine, an anticonvulsant, works remarkably well, and a good response to it is so characteristic that it helps confirm the diagnosis.
People suffer with this for years before it is named. It should not take years. The pattern is distinctive enough to recognise in a single consultation.
What sets it off is light touch, not pressure. A breeze on the face triggers it; pressing firmly on the same spot often does not. That inversion is highly characteristic and worth mentioning to whoever assesses you.
People start avoiding these things — eating on one side, not shaving, keeping a scarf over the face, avoiding conversation. That avoidance is often the first thing a partner notices.
Constant background aching, numbness, or pain on both sides at once. Those features suggest a secondary cause and change what needs investigating.
This condition has historically been called the suicide disease, and that is not hyperbole. Severe untreated facial pain, often dismissed for years, causes real desperation. If you are struggling, say so — to us, to your GP, or to Samaritans on 116 123. The pain is treatable, and so is the despair that comes with it.
In most cases a small loop of artery presses on the trigeminal nerve where it leaves the brainstem, wearing away its insulating sheath over years. The nerve then misfires, turning a light touch into a signal the brain reads as agony.
This is why it becomes commoner with age — blood vessels lengthen and become more tortuous over time.
Most commonly over 50, and somewhat more often women. It is uncommon overall, which is part of why it goes unrecognised.
Trigeminal neuralgia is a clinical diagnosis. Four features together make it very likely:
Complete freedom from pain between attacks supports it further.
Facial sensation should be normal. Numbness is the single most important abnormal finding, because it points to a secondary cause. Corneal reflex, jaw strength, hearing and eye movements are all checked.
MRI is recommended for everyone with a new diagnosis, to look for vascular compression, MS or a tumour. It is not always done in practice, and it is worth asking about — particularly if you are under 50.
Full blood count, sodium and liver function, repeated during treatment. Carbamazepine commonly lowers sodium, which causes confusion and unsteadiness and is easily attributed to something else.
HLA-B*1502 testing before starting carbamazepine, for people of Han Chinese, Thai or certain other South East Asian ancestry.
This suits a remote consultation well, because the diagnosis is made almost entirely on the description of the pain — and because getting it named quickly is what matters most.
We will not prescribe opioids for this — and not simply because we do not prescribe them at all. They do not work for trigeminal neuralgia. Escalating through stronger painkillers is a well-trodden path to no benefit and real harm.
Surgical options exist and work well. Microvascular decompression — lifting the blood vessel off the nerve — offers the best long-term results. Gamma knife and radiofrequency treatments are less invasive alternatives.
These are worth asking about rather than waiting to be offered, particularly if medication is failing or its side effects are intolerable.
This is not a condition where private care provides better treatment. Carbamazepine is carbamazepine. Where private care helps is speed — and with this pain, speed matters more than usual.
This page follows NICE guideline CG173 on neuropathic pain in adults, NICE Clinical Knowledge Summaries on trigeminal neuralgia, and European Academy of Neurology guidance, alongside MHRA safety advice on carbamazepine.
Guidance recognises the substantial psychological burden of trigeminal neuralgia, including anxiety, depression and suicidal ideation, and advises that mood be assessed alongside pain control.
Reviewed against NICE CG173, NICE CKS, EAN and MHRA guidance current at the date shown above.
Almost certainly not, if the pain comes in brief electric shocks set off by light touch or a breeze. Toothache is constant, throbbing, and worse with hot and cold.
If dental treatment has not helped, stop before another extraction. People lose healthy teeth to this every year.
Because this is nerve pain, and paracetamol, ibuprofen and opioids do not act on the mechanism causing it.
Increasing the dose does not help — you need a different class of drug entirely, and carbamazepine is that drug.
Because it calms misfiring nerves, which is exactly what is happening here. The nerve has lost some of its insulation and is firing at the slightest touch.
Carbamazepine dampens that, and a good response is characteristic enough to support the diagnosis.
Because the damaged nerve misinterprets light touch specifically. It is one of the most distinctive features of the condition.
Mention it when you are assessed — it is a strong pointer and is easy to describe.
An MRI is recommended, to look for a blood vessel pressing on the nerve, or occasionally MS or a tumour.
It matters most if you are under 50, have pain on both sides, or have any numbness. It is worth asking about if it has not been offered.
Usually not. Most trigeminal neuralgia is caused by a blood vessel pressing on the nerve.
MS is a recognised cause and is more likely in younger people or with bilateral pain, which is precisely why the scan is recommended.
Many people have long remissions, sometimes months or years. Medication can often be reduced during those, under supervision.
It does tend to return, and attacks often become more frequent over time — which is why surgery is worth discussing if tablets stop working.
Microvascular decompression lifts the blood vessel off the nerve and gives the best long-term results.
Gamma knife and radiofrequency treatments are less invasive alternatives, and are available on the NHS at specialist centres.
Yes — it makes hormonal contraception less reliable, and this is missed surprisingly often.
Raise it before starting, not afterwards, so an alternative can be arranged.
Yes, and you are not being dramatic. This is recognised as one of the most severe pains there is, and the psychological toll is well documented.
Say so to whoever is treating you, and contact Samaritans on 116 123 if you need to talk to someone now. The pain is treatable.
August 30, 2026
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If your problem turns out to be genuinely outside what we can do remotely, the doctor will tell you straight away, point you to the right service, and refund your fee in full. We would rather do that than fill twenty minutes to justify the charge.
Call 999 or go to A&E — do not book an online appointment and do not wait for a reply to an email. For urgent problems that are not emergencies, NHS 111 is available 24 hours a day, online or by phone, and can direct you to the right service.
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