The classic story is this. A 58-year-old marketing director shaves Sunday morning and an electric shock fires through the right cheek into the upper teeth. It lasts four seconds. By Wednesday, taking a sip of cold water sets it off. By Friday, smiling at a coworker becomes dangerous. By the time the patient is in our office, they have lost six pounds because chewing on the right side is too risky to attempt.
That is trigeminal neuralgia. It is one of the most painful conditions in clinical medicine — the original “suicide disease” — and it is also one of the most treatable, provided the right diagnosis is made early and the right ladder is followed. The hard part is that trigeminal neuralgia is one of roughly a dozen distinct facial and cranial nerve pain syndromes that present in superficially similar ways but require very different treatment paths. Misdiagnosis is common: most of our trigeminal neuralgia patients arrive after months of being told they have a “dental problem” or “atypical migraine.”
This page covers the differential, the diagnostic workup, and the procedural ladder we use at Modal Pain Management NYC, 369 Lexington Avenue Floor 25 in Midtown Manhattan. Dr. Alex Movshis is dual board-certified in Anesthesiology and Pain Medicine and fellowship-trained in interventional pain medicine at the Icahn School of Medicine at Mount Sinai. Same-week new-patient consultations are routinely available.
When facial pain isn’t a dental problem — the diagnostic differential
The first job at the new-patient visit is to assign your pain to one of the following categories. Each has a different mechanism, a different diagnostic workup, and a different procedural answer. The category drives every downstream decision.
Classical trigeminal neuralgia (TGN, type 1). Brief — seconds to two minutes — electric, lancinating attacks confined to one or more divisions of the trigeminal nerve, almost always V2 (cheek and upper lip) or V3 (lower jaw). V1 (forehead, eye) is uncommon and should raise concern for shingles. Pain is triggered by light touch to a cutaneous “trigger zone” — shaving, brushing teeth, washing the face, a cold draft, chewing, speaking, even a kiss. Pain crosses the midline only rarely; bilateral TGN is a red flag for multiple sclerosis. Between attacks, the patient is pain-free.
Trigeminal neuralgia type 2 (TGN2) or trigeminal neuropathic pain. A constant aching or burning component layered onto the lancinating attacks. This pattern responds less reliably to microvascular decompression and is more likely to require a multimodal medication-plus-procedure approach.
Post-herpetic neuralgia (PHN) of the trigeminal distribution. Severe burning, allodynic pain in the dermatomal distribution of a healed shingles outbreak — most commonly the V1 (ophthalmic) distribution after herpes zoster ophthalmicus. The pain is not paroxysmal in the way TGN is — it is a near-constant burn punctuated by lancinating exacerbations. The history of a recent or remote zoster outbreak is the diagnostic anchor.
Occipital neuralgia (greater, lesser, or third occipital). Suboccipital pain that radiates over the back of the head toward the eye, sometimes reproduced by gentle tapping over the occipital nerve at the superior nuchal line (positive Tinel sign). Often confused with chronic migraine because it produces a similar headache-pattern symptom profile. An occipital nerve block helps sort them out, with a caveat: blocks also ease migraine, so clear relief supports occipital neuralgia without proving it (Dougherty 2014).
Glossopharyngeal neuralgia. Brief, sharp, lancinating pain in the throat, posterior tongue, tonsillar fossa, or ear triggered by swallowing, coughing, talking, or yawning. The clinical pearl: a small subset of patients have vagal-mediated syncope or bradycardia with attacks, so a cardiology workup is part of the evaluation.
Sphenopalatine ganglion–mediated pain. Pain in the upper face and forehead, often accompanied by autonomic features (lacrimation, conjunctival injection, ptosis, miosis, nasal congestion or rhinorrhea). In its severe paroxysmal form this is cluster headache. In milder forms it overlaps with chronic migraine and atypical facial pain. One diagnostic and therapeutic option is a transnasal sphenopalatine ganglion block.
Persistent idiopathic facial pain (PIFP, formerly atypical facial pain). Constant, dull, aching, poorly localized facial pain that does not respect dermatomal boundaries and does not respond to carbamazepine. The diagnosis is one of exclusion. Treatment is multimodal and PIFP patients should be evaluated for psychiatric comorbidity in parallel with interventional care.
Temporomandibular disorder (TMD). Pain in the preauricular region, jaw, masseter, or temporalis with mechanical jaw symptoms (clicking, locking, restricted opening) and tenderness on palpation of the masseter and temporalis. This is sometimes presented as “facial nerve pain” but the right page for it is jaw pain & TMJ.
Post-traumatic trigeminal neuropathy. Persistent neuropathic pain in a trigeminal distribution after dental extraction, third molar surgery, dental implant placement, endodontic treatment, orthognathic surgery, or facial trauma. Mechanism is direct nerve injury; treatment overlaps with PHN.
Geniculate neuralgia and other rare cranial neuralgias. Deep ear pain triggered by stimulation of the external auditory canal. Rare. Requires ENT and pain medicine co-management.
The differential matters because the procedural answers are not interchangeable. A patient with classical TGN gets a different ladder than a patient with PIFP, and giving the wrong treatment to the wrong patient is the most common reason facial pain is “refractory” — it usually means a different pain generator is in play than the one that has been treated.
The diagnostic workup: what we order and why
The clinical history and physical examination do most of the diagnostic work. Targeted imaging and, when useful, a diagnostic block do the rest.
MRI brain with trigeminal protocol. Every new TGN patient under age 60, every patient with bilateral or V1-dominant symptoms, every patient with sensory loss on cranial nerve examination, and every patient with atypical features gets an MRI. The protocol is thin-cut FIESTA/CISS (constructive interference in steady state) plus standard sequences, with attention to the cerebellopontine angle and the trigeminal cisternal segment. We are looking for three things: a blood vessel pressing on the trigeminal nerve at the root entry zone (in a blinded 3-tesla MRI study of 135 patients with classical TGN, contact severe enough to displace or shrink the nerve was found on the painful side in 53% and on the painless side in 13%, Maarbjerg et al., 2015), a cerebellopontine angle tumor (vestibular schwannoma, meningioma, epidermoid — uncommon but life-changing to find), and demyelinating plaques suggesting multiple sclerosis. For patients with persistent V1 pain after shingles, MRI also rules out herpes zoster meningoencephalitis.
Multiple sclerosis screen for trigeminal neuralgia in younger patients. TGN in a patient under 40, or bilateral TGN at any age, prompts neurology referral and a full MS workup including brain and cervical cord MRI with gadolinium.
Targeted laboratory workup. Diabetes is an independent risk factor for cranial neuropathies, so an A1C is part of the new-patient panel. For atypical or refractory facial pain we add ANA, Sjögren’s antibodies, ACE level (sarcoidosis), Lyme serology in appropriate exposure histories, and inflammatory markers.
Diagnostic divisional or peripheral nerve block. A diagnostic block is one of the most useful ways to test which nerve carries the pain. For suspected TGN we perform an ultrasound-guided block of the affected peripheral branch: the infraorbital nerve for V2, the mental or mandibular nerve for V3. For suspected occipital neuralgia, an ultrasound-guided greater occipital nerve block. For suspected sphenopalatine ganglion involvement, a transnasal catheter SPG block. A clear drop in the usual pain while the anesthetic works makes that nerve the likely source, not a certainty, and the corresponding treatment plan is set up. If the block gives little or no relief, the working diagnosis is probably wrong and the workup pivots.
The procedural ladder for trigeminal neuralgia
The first move is medical, the second is procedural, and the third is referral. The order matters and is based on randomized-trial and case-series evidence going back to the carbamazepine trials of the 1960s.
Step 1 — carbamazepine trial. Carbamazepine (Tegretol) or oxcarbazepine (Trileptal) are the first-choice medications for classical TGN (Bendtsen 2019). Some patients tolerate oxcarbazepine better. Most patients with classical TGN respond, at least at first, and a clear response supports the diagnosis. For patients who cannot tolerate carbamazepine — typical reasons include drowsiness, dizziness, hyponatremia, leukopenia, or rash — gabapentin, pregabalin, baclofen, or lamotrigine are reasonable second-line agents.
Step 2 — ultrasound-guided peripheral branch block. For patients with a clear TGN diagnosis who are not getting durable relief from medication, or who cannot tolerate medication side effects, the next step is a diagnostic-therapeutic peripheral branch nerve block. We perform these under ultrasound guidance at the peripheral branches: the infraorbital nerve for V2 and the mental and mandibular nerves for V3. A small volume of local anesthetic, with or without a steroid, is delivered onto or near the target nerve. How long relief lasts varies a lot from person to person, and the evidence for blocks in TGN comes from small studies. The block can be repeated. Patients whose relief keeps getting shorter are referred to neurosurgery to discuss the procedures below.
Step 3 — percutaneous ganglion procedures (referral). For patients who respond clearly to branch blocks but get shorter relief with each repeat, the next conversation is a procedure at the Gasserian ganglion: balloon compression, glycerol rhizotomy, or radiofrequency thermocoagulation of the ganglion, performed by neurosurgery partners. These treat the ganglion inside the skull base, not a branch in the face. In the largest series of ganglion radiofrequency, 1,600 patients, 57.7% of those treated once were completely pain-free at 5 years (Kanpolat 2001). The trade-off is facial numbness, and in some patients unpleasant numbness (dysesthesia, 23% in one prospective series, mostly mild) or a weaker corneal reflex (Taha 1995). Apart from pulsed radiofrequency of the supraorbital nerve for post-herpetic neuralgia (below), radiofrequency of a trigeminal branch is not performed at Modal Pain Management NYC. Thermal radiofrequency of a branch such as the infraorbital nerve is supported mainly by retrospective studies: in one cohort of 92 patients with V2 trigeminal neuralgia, radiofrequency of the infraorbital or maxillary nerve, chosen by which block worked, reduced pain in both groups, though in the infraorbital group pain scores crept back up over the first six months (Dong 2026). Pulsed radiofrequency (PRF) has done poorly in trigeminal neuralgia: in a randomized trial of 40 patients treated at the ganglion, pain improved in only 2 of 20 after PRF, compared with clear relief after conventional thermal radiofrequency (Erdine 2007), and a later review judged PRF not appropriate for TGN (Chang 2018).
Step 4 — microvascular decompression (MVD) referral. For medically refractory classical TGN with imaging-confirmed neurovascular compression at the trigeminal root entry zone, the surgical option with the longest-lasting results is microvascular decompression — a posterior fossa craniotomy in which the offending vessel is mobilized off the nerve and a Teflon sponge is placed between them. In the largest long-term series, 1,185 patients, 70 percent were free of pain without medication 10 years after surgery, and the rare serious complications included two deaths (0.2 percent) and hearing loss on the operated side in 1 percent (Barker et al., NEJM, 1996). We coordinate referral to New York City neurosurgeons for evaluation. In that series, female sex, venous rather than arterial compression, symptoms lasting more than eight years, and pain that did not stop right after surgery predicted a higher chance of recurrence. MVD tends to suit patients with classical (type 1) TGN, clear arterial compression on FIESTA imaging, and no superimposed constant pain.
Step 5 — stereotactic radiosurgery referral (Gamma Knife, CyberKnife). For patients who are not surgical candidates — older patients, patients with multiple comorbidities, anticoagulated patients — stereotactic radiosurgery delivers a focused dose of radiation to the trigeminal root entry zone. Relief is delayed, often by weeks or more, and the response is generally less durable than MVD, but the procedure is non-invasive and well-tolerated. Several New York City hospitals run trigeminal radiosurgery programs, and we refer to them.
Treatment paths for the other facial nerve pain syndromes
Occipital neuralgia. First-line is medication (gabapentinoid plus topical lidocaine) and posture/ergonomic work, but most patients reach Modal because medication has failed. The fast diagnostic move is an occipital nerve block with local anesthetic, placed by landmarks or ultrasound. Clear relief supports the diagnosis, but blocks also ease migraine, so relief alone does not prove where a headache starts (Dougherty 2014). Patients who get clear relief from blocks that keeps wearing off are candidates for pulsed radiofrequency (PRF) of the greater occipital nerve. In a double-blind trial of patients with occipital neuralgia or migraine with occipital tenderness, it eased occipital pain more than the comparison injection through 6 months, though the trial was too small to show the difference in the occipital neuralgia patients alone (Cohen 2015), and a 2024 systematic review found relief lasting 6 to 10 months in occipital neuralgia, from low-quality evidence (De Oliveira 2024). For severe cases that fail these steps, we refer for occipital nerve stimulation.
Post-herpetic neuralgia. First-line is gabapentinoid plus topical agent (5% lidocaine patch, 8% capsaicin patch). For patients with refractory V1 PHN we offer ultrasound-guided supraorbital and supratrochlear nerve blocks (V1 distal branches). For patients who get clear but short-lived relief from those blocks, pulsed radiofrequency (PRF) of the supraorbital nerve is an option. PRF is not an ablation: it calms the nerve at about 42 °C without burning it. A 2018 review counted post-herpetic neuralgia among the conditions where PRF has supporting evidence, though the studies are small (Chang 2018). When it works, relief often lasts weeks to a few months, and it can be repeated. Stellate ganglion block is an option for sympathetically-maintained components.
Sphenopalatine ganglion–mediated pain. Transnasal sphenopalatine ganglion block is performed in-office using a thin catheter passed along the floor of the nasal cavity to the posterior nasal wall, delivering local anesthetic to the SPG. The procedure takes five minutes, requires no needle, and acts within minutes. The best controlled evidence is in chronic migraine: in a small double-blind trial of 38 patients, repeated bupivacaine SPG blocks lowered pain scores more than saline at 15 minutes, 30 minutes and 24 hours (Cady 2015). The evidence for cluster headache and facial pain with autonomic features is thinner. Patients who respond well can have the block repeated.
Glossopharyngeal neuralgia. Carbamazepine is first-line as for TGN. Patients with vagal-mediated cardiac symptoms during attacks need a cardiology workup. Refractory cases are referred to neurosurgery for evaluation, including MVD of the glossopharyngeal nerve.
Persistent idiopathic facial pain. Mechanism is poorly understood and the response to interventional procedures is uneven. We use a structured trial of medication (tricyclic antidepressant or SNRI plus topical agent), evaluate for and treat comorbid TMD, screen for and refer comorbid depression and anxiety, and offer diagnostic blocks selectively to rule in or rule out a peripheral generator. Patients who get clear relief from a peripheral block become candidates for that target’s procedural ladder. Patients who get no relief receive ongoing multimodal medical management rather than escalating procedural intervention.
What to expect at your first visit
The new-patient consultation takes 45–60 minutes and may include an ultrasound exam. Bring your full medication trial history with doses, your prior imaging on disc or via patient portal (we read your MRI ourselves during the visit), any neurology, ENT, or dental notes, and a brief written timeline of your pain — when it started, what triggers it, what makes it better, what has been tried. The timeline document is the single most useful artifact a new patient can bring.
The visit covers focused history, cranial nerve examination (corneal reflex, light touch in V1/V2/V3 distributions, masseter strength, sensory threshold testing), examination for occipital, TMJ, and cervical findings, and review of any prior imaging. The end product of the visit is a working diagnosis, a recommended next step (medication, imaging, or diagnostic block), a clear timeline for procedural scheduling if appropriate, and a written care plan you take with you.
If a procedure is indicated, it is almost always scheduled separately after benefits verification rather than performed the same day. Image-guided trigeminal branch (infraorbital, mental and mandibular), occipital, supraorbital, and supratrochlear blocks are performed in our procedure suite at 369 Lexington under local anesthesia, typically without IV sedation, with same-day discharge. Sphenopalatine ganglion blocks are performed in the clinic exam room. Radiofrequency procedures are usually done without sedation. If you want sedation, the procedure is done at a surgical center.
When to come in versus when to go to the emergency room
A few features mean you should call 911 or go to the nearest emergency room rather than book a routine consultation: new severe headache that is the worst headache of your life (“thunderclap headache”), new neurological deficits (weakness, sensory loss, double vision, drooping eyelid, facial droop in a non-trigeminal pattern), new confusion or altered mental status, signs of meningitis (stiff neck, fever, photophobia), and shingles outbreak in the V1 distribution with eye involvement.
For everything else — established chronic facial pain that has not responded to dental, ENT, or neurology workup, suspected TGN that needs a firm diagnosis and a treatment plan, occipital neuralgia masquerading as migraine, refractory PHN — the appropriate cadence is same-week routine consultation. Most commercial PPO plans cover consultation and image-guided procedures, often with prior authorization that we handle on your behalf. We accept most commercial PPO plans, including Aetna, Anthem Blue Cross Blue Shield, Cigna, Empire Blue Cross Blue Shield, the Empire Plan, Oscar, Oxford, UMR and UnitedHealthcare, and do not accept Medicare, Medicaid, HMO plans, or workers’ compensation. Coverage for radiofrequency procedures varies from plan to plan, so the office checks your plan’s policy first.
To schedule, book online or call (646) 290-6660. Dr. Movshis sees every patient personally at every visit — initial consultation through follow-up.
References
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