Novel Insights into the Management of Painful Trigeminal Neuropathy: Targeting Peripheral and Central Pathomechanisms

Painful trigeminal neuropathy (PTN) is a very disabling but often unrecognized facial pain from various etiologies. Patients with PTN suffer from persistent, intense facial pain with significantly impaired sensory function in the trigeminal territories. This article reviews the anatomy and pathophysiology of PTN, as well as its clinical presentation and management. The peripheral inflammatory cascades, including immune cell activation, inflammatory mediator-induced nociceptor activation, and sensory hyperexcitability in the trigeminal nerve, are discussed, as are the central sensitization processes, including postsynaptic NMDA receptor activation, glial cell-mediated inflammation, and reduced inhibitory pathways in the central nervous system. A comprehensive literature review that covers multiple specialties and discusses various treatment options based on the available evidence is presented. Collectively, a practical algorithm is proposed to improve current PTN management. It provides novel guidance for managing PTN in an evidence-based, integrative, and mechanism-specific approach. In conclusion, a multidisciplinary team approach targeting both peripheral and central sensitization would be an ideal strategy for delivering optimal, mechanism-specific management in painful trigeminal neuropathy.