"I went to a neurologist and he told me it's all in my head"... This sentence, or something similar, repeated by many people with trigeminal neuropathic pain, gives a clear picture of not only a lack of knowledge but also a lack of empathy that still occurs in patient interactions. For someone suffering from this type of pain, words of misunderstanding — even cruel ones — can be as painful as the symptoms themselves: they undermine the patient's experience, delay proper diagnosis, and take away hope for understanding and effective treatment.
Pain involving the trigeminal nerve ranks among the most debilitating conditions affecting the face. Such comments reveal how limited awareness remains — not only in society but, worse, within healthcare itself — regarding the different forms of neuropathic pain and how often patient experiences are misjudged or dismissed.
Many people treat such pain as "ordinary pain" or assume that if someone functions day to day, they can't possibly be suffering as much as they describe. That is untrue.
Both trigeminal neuralgia and painful trigeminal neuropathy can cause immense suffering and significantly reduce quality of life.
Trigeminal neuralgia
Though we all know this description well, I'll repeat it once more. Trigeminal neuralgia is a condition dominated by brief, very intense pain attacks. Patients describe them as piercing, stabbing, or like an electric shock. Attacks usually last from seconds to approximately 2 minutes, appear suddenly, and resolve just as suddenly. They most commonly affect one side of the face, involving the jaw, cheek, teeth, or gums.
An attack can be triggered by touching the face, brushing teeth, eating, speaking, shaving, or even a light breeze or air conditioning. This is precisely why the condition is often confused with a dental problem, even though the source of pain lies in the nerve.
Painful trigeminal neuropathy
A different but equally important problem is painful trigeminal neuropathy. Here, pain more often has a constant and/or chronic character: it may be burning, searing, squeezing, dull, or pressure-like. Sensory disturbances frequently coexist — numbness, tingling, hyperesthesia, or pain triggered by even light touch.
Painful post-traumatic trigeminal neuropathy should be considered especially when a patient reports chronic pain present nearly all the time, not just brief paroxysms. That is precisely why a physician should not lump all "trigeminal nerve pain" together — neuralgia and neuropathy are not the same thing.
The difference that must be known
In simplified terms: neuralgia is primarily paroxysmal pain, while neuropathy is more often continuous pain related to nerve damage. In practice, the picture may overlap — some patients have both attacks and a background of chronic pain. Nevertheless, the distinction matters because it affects diagnostics, treatment selection, and further management.
In neuralgia, the focus is often on vascular compression of the nerve. In neuropathy, the focus is on NERVE DAMAGE from various causes: trauma, demyelinating disease, tumor, inflammation, autoimmune condition, or procedural complication (including aesthetic medicine). That's why with facial pain, it's not enough to fight the symptom alone — you must also search for the cause.
How diagnosis should work
Diagnosis relies primarily on thorough history, neurological examination, and assessment of whether imaging — usually MRI — is needed.
In neuralgia: brief pain attacks, unilaterality, and triggers are key.
In neuropathy: continuous or near-continuous symptoms, sensory disturbances, and signs of nerve damage (numbness, tingling, hyperesthesia, reduced sensation, allodynia) are key.
Patients very often see a dentist first because pain radiates to teeth and gums. This is understandable — trigeminal nerve branches innervate exactly these structures, so nerve pain can feel like tooth, gum, or jaw pain. That's why the problem is often confused with dental inflammation, even though the source lies in the nervous system.
Treatment
In trigeminal neuralgia, first-line drugs are usually antiepileptics, especially carbamazepine and oxcarbazepine. In some cases, other medications are used: gabapentin, pregabalin, lamotrigine, or baclofen. If pharmacological treatment fails or is poorly tolerated, procedural treatment is considered, including microvascular decompression or other specialist procedures.
In painful trigeminal neuropathy, treatment depends on the cause and clinical picture. The goal is not only pain relief but also identifying the underlying condition, if one exists. This is particularly important because neuropathy may be a symptom of a more serious problem requiring urgent investigation.
Why antidepressants are used
In neuropathic pain, including trigeminal conditions, certain antidepressants have analgesic effects because they strengthen the nervous system's natural pain "brakes." Most commonly these are tricyclic antidepressants (like amitriptyline) and SNRIs (like duloxetine).
The mechanism isn't about mood improvement per se, but about modulating pain signal conduction. These drugs affect serotonin and noradrenaline — substances involved in descending pain inhibition pathways — and some data also indicate anti-allodynic and anti-hyperalgesic effects.
What we should never hear in a medical office
Most importantly, the words "nothing is wrong with you" or "it's all in your head" should never be spoken. Both neuralgia and painful trigeminal neuropathy are real neurological conditions, and their pain can be very severe even though the patient may sometimes look "normal" on the outside.
In a medical office — a place where we seek help and understanding — three things should be said: that the pain is real, that specific diagnostic criteria exist, and that treatment methods are available. Such a conversation not only reduces fear but also helps patients reach the right specialist faster and avoid unnecessary repeated dental procedures or symptomatic treatments that don't work.
Why this matters socially
Online discussions about facial pain often reveal a lack of social awareness — but even more often they reveal a lack of empathy in specialist offices.
In pain conditions, the worst part is often not only the physical suffering but also years of having one's experience questioned. That's why we need to talk about these conditions clearly, simply, and without dismissiveness.
References:
Melek LN et al. Comparison of the Neuropathic Pain Symptoms and Psychosocial Impacts of Trigeminal Neuralgia and Painful Posttraumatic Trigeminal Neuropathy. *Journal of Oral & Facial Pain and Headache*, 2019.
Veerapaneni KD et al. Trigeminal Neuropathy. StatPearls Publishing.
Markowitz VM. Painful Trigeminal Neuropathy. Master's thesis, University of Zagreb, 2024.
Natalia — since 2014 I've been living with trigeminal nerve pain. I write in plain language, based on reliable sources and personal experience. Read my story →
Frequently Asked Questions
What is trigeminal neuralgia?
Trigeminal neuralgia is a chronic facial pain condition. It manifests as sudden, severe, usually one-sided pain attacks — often described as an electric shock. A single attack typically lasts from a few seconds to about two minutes.
What is the difference between neuralgia and neuropathy?
In simple terms: neuralgia primarily involves paroxysmal pain along a nerve, usually without loss of sensation. Neuropathy involves nerve damage that more often causes constant pain along with numbness and sensory loss.
Do regular painkillers help with neuropathic pain?
Usually not. Neuropathic pain responds poorly to paracetamol or anti-inflammatory drugs. Instead, medications that act on nerves are used, such as anticonvulsants like carbamazepine.
How does carbamazepine work for trigeminal neuralgia?
Carbamazepine is the first-line medication for trigeminal neuralgia. In a large proportion of patients, it provides effective pain control. It requires gradual dose adjustment and medical supervision.
What is the difference between gabapentin and pregabalin?
Both are anticonvulsant medications used for neuropathic pain. They differ in absorption and dosing characteristics. The choice and dosage should be determined by a physician.
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