Current understanding suggests that classical trigeminal neuralgia is most often caused by focal demyelination where a blood vessel compresses the trigeminal nerve near the brainstem.
This damage can trigger abnormal electrical activity, ephaptic transmission between nerve fibers, and hyperexcitability, leading to sudden attacks of severe facial pain.
Several complementary theories have been proposed, but they all emphasize the importance of demyelination and abnormal nerve signaling in the development of trigeminal neuralgia.
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