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Cranial Neuralgias: Causes of Facial and Head Pain, Diagnosis, and Modern Treatment Approaches

What Are Cranial Neuralgias?

Cranial neuralgias are a group of disorders characterized by brief, sharp, shooting, or electric shock–like pains in the area supplied by a specific cranial nerve. Attacks may last from a few seconds to several minutes and are often triggered by talking, chewing, touching the skin, or even a mild breeze.

Because the pain can mimic migraine, sinusitis, or dental issues, misdiagnosis is common. Correct identification of the affected nerve allows significant reduction of symptoms using modern therapeutic approaches, including medication, injections, and interventional procedures.

Main Types of Cranial Neuralgias

1. Trigeminal Neuralgia

Characterized by sharp, intense, shooting pain occurring in one or more branches of the trigeminal nerve — cheek, lower jaw, teeth, lip, or the area around the eye. This is one of the most severe pain syndromes in neurology.

More information on botulinum toxin therapy in this condition: Botulinum Toxin Therapy for Trigeminal Neuralgia

2. Occipital Neuralgia

Pain originates in the occipital region and may spread to the crown, temples, or behind the eyes. Symptoms often worsen with neck movements or with light pressure on the scalp.

3. Glossopharyngeal Neuralgia

Pain arises deep in the throat, at the root of the tongue, in the ear, or under the lower jaw. Swallowing, talking, or yawning often provoke attacks.

4. Nervus Intermedius Neuralgia

A rare condition presenting with sharp deep ear pain. It may be accompanied by reduced tear production or taste disturbances.

5. Neck–Tongue Syndrome

Sudden sharp pain in the occipital area when turning the head, accompanied by unusual sensations on one side of the tongue. More common in younger patients.

Why Does Sharp Neuralgic Pain Occur?

Main underlying mechanisms include:

  • nerve compression by a vessel, muscle, or bone structure;
  • demyelination (for example, in multiple sclerosis);
  • viral infections — especially herpes zoster;
  • trauma to the face or neck;
  • central sensitization, leading to increased excitability of brain pain centers.

How Diagnosis Is Performed

Accurate diagnosis is essential for choosing the right treatment strategy and determining whether a secondary cause is present. Evaluation typically includes:

  • detailed clinical history;
  • full neurological examination;
  • MRI of the brain and neck with thin slices along cranial nerve pathways;
  • exclusion of dental, ENT, and vascular causes.

Modern Treatment Approaches

1. Medication Therapy

Medications that reduce pathological nerve activity include carbamazepine, oxcarbazepine, gabapentin, pregabalin, lamotrigine, and baclofen.

2. Therapeutic Nerve Blocks

Local injections near the affected nerve may provide significant relief, especially in occipital neuralgia.

3. Botulinum Toxin Therapy

A modern, evidence-based option that can reduce the frequency and intensity of attacks in various neuralgias. Particularly effective for:

  • trigeminal neuralgia,
  • occipital neuralgia,
  • chronic neuropathic facial pain.

More details: Botulinum Toxin Therapy in Neurology

4. Interventional and Surgical Treatments

For severe and persistent pain, the following methods may be used:

  • radiofrequency ablation,
  • chemical neurolysis,
  • microvascular decompression when a vascular conflict is present.

When to See a Neurologist

Seek medical attention if:

  • the pain feels like an electric shock,
  • attacks occur frequently,
  • even light touching of the face triggers pain,
  • the condition affects sleep, eating, or daily functioning.

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. https://doi.org/10.1177/0333102417738202
  2. International Classification of Orofacial Pain (ICOP). Cephalalgia. 2020;40(2):129–221. https://doi.org/10.1177/0333102419893823
  3. De Toledo IP, et al. Prevalence of trigeminal neuralgia: a systematic review. J Am Dent Assoc. 2016;147(7):570–576.e2. https://doi.org/10.1016/j.adaj.2016.02.014
  4. Cruccu G, et al. AAN–EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008;15(10):1013–1028. https://doi.org/10.1111/j.1468-1331.2008.02185.x
  5. Bendtsen L, et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019;26(6):831–849. https://doi.org/10.1111/ene.13950
  6. Lambru G, Zakrzewska J, Matharu M. Trigeminal neuralgia: a practical guide. Pract Neurol. 2021;21(5):392–402. https://doi.org/10.1136/practneurol-2020-002782
  7. Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain. 2001;124(Pt 12):2347–2360. https://doi.org/10.1093/brain/124.12.2347
  8. Gambeta E, Chichorro JG, Zamponi GW. Trigeminal neuralgia: overview from pathophysiology to treatments. Mol Pain. 2020;16. https://doi.org/10.1177/1744806920901890
  9. Robblee J. Nervus intermedius neuralgia: case reports and review. Headache. 2021;61(3):414–421. https://doi.org/10.1111/head.14066
  10. Gelfand AA, et al. Neck-tongue syndrome: a systematic review. Cephalalgia. 2018;38(2):374–382. https://doi.org/10.1177/0333102416681570
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