Trigeminal neuralgia differential diagnosis

Overview:

The differential diagnosis of TN includes the conditions that cause classic TN and secondary TN, mainly compression of the trigeminal nerve by a vascular loop or a nonvascular space-occupying lesion, and demyelination from multiple sclerosis in the pons or root entry zone of the trigeminal nerve. Although less likely to be confused with TN, the differential diagnosis also includes various causes of painful trigeminal neuropathy, such as acute herpes zoster, postherpetic neuralgia, and trauma to the trigeminal nerve. In most cases, painful trigeminal neuropathy can be distinguished from TN by a thorough history and examination. A history of persistent pain or pain that occurs episodically in attacks lasting longer than two minutes eliminates classical trigeminal neuralgia and should lead to a search for other diagnoses. The pain of glossopharyngeal neuralgia, which may be triggered by talking or swallowing, is located in the tongue and pharynx.. Some differentials are listed in the table below:

Differential diagnosis of trigeminal neuralgia

Diagnosis	Differentiating features
Glossopharyngeal neuralgia	Pain in tongue, mouth, or throat; brought on by swallowing, talking, or chewing
Cluster headache	Longer-lasting pain; orbital or supraorbital; may cause patient to wake from sleep; autonomic symptoms
Cluster tic syndrome	Cluster headache with coexistent trigeminal neuralgia
Primary stabbing headache	Transient; sharp jabbing pains; variable locations within trigeminal and cervical dermatomes
Dental pain (e.g., caries, cracked tooth, pulpitis)	Localized; related to biting or hot or cold foods; visible abnormalities on oral examination
Migraine	Longer-lasting pain; associated with photophobia and phonophobia; family history
Giant cell arteritis	Persistent pain; temporal; often bilateral; jaw claudication
Otitis media	Pain localized to ear; abnormalities on examination and tympanogram
Paroxysmal hemicrania	Pain in forehead or eye; autonomic symptoms; lasts only seconds; do not respond to carbamazepine
Sinusitis	Persistent pain; associated nasal symptoms
Temporomandibularjoint syndrome	Persistent pain; localized tenderness; jaw abnormalities
Post herpetic neuralgia	Continuous pain; tingling; history of zoster; often first division
Trigeminal neuropathy	Persistent pain; associated sensory loss
SUNCT/SUNA	Severe unilateral head pain in orbital, periorbital, or temporal regions; ipsilateral autonomic symptoms

SUNCT: short lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing

SUNA: short lasting, unilateral, neuralgiform headache attacks with autonomic symptoms