Most face pain after 50 has a dull, ordinary explanation: a cracked filling, a sinus infection, a grinding habit that has caught up with you. Trigeminal neuralgia is not that. It arrives as a jolt, it lasts seconds, and it is set off by a cold breeze on the way to the car or the first touch of a toothbrush. It affects roughly four or five people in every 100,000 each year, but it clusters in exactly the age group this site is written for: more than nine in ten people are over 40 when it starts, and onset most often falls between 52 and 58. It is also one of the most commonly mistreated conditions in medicine, and the mistreatment usually happens in a dentist’s chair.
TL;DR
- Trigeminal neuralgia causes sudden, electric-shock pain on one side of the face, lasting seconds to about two minutes, triggered by light touch, cold air, chewing or talking.
- It is frequently mistaken for dental pain, and in published series most people had irreversible dental work before the correct diagnosis.
- About 80% of cases come from a blood vessel pressing on the trigeminal nerve root. Around 15% are secondary to another condition, most often multiple sclerosis, which is why an MRI matters.
- Carbamazepine is the first-line medicine and often works dramatically, but after 50 it needs sodium, blood count and liver monitoring.
- When medicines fail, surgery is a reasonable next step rather than a last resort: microvascular decompression keeps about three quarters of people well at five years.
What the pain actually feels like
The trigeminal nerve carries sensation from the face in three branches: forehead and eye, cheek and upper teeth, jaw and lower teeth. Trigeminal neuralgia usually affects the lower two, on one side only, which is precisely why the teeth get blamed. The pain is sudden and severe, described as electric, stabbing or like a hot wire. Each attack lasts from a second to around two minutes, and attacks come in volleys with pain-free gaps between them. It is provoked rather than spontaneous: shaving, applying make-up, brushing teeth, a draught of cold air, chewing, even speaking. And there are often remissions, weeks or months when it disappears entirely and you allow yourself to believe it has gone for good.
Why it gets treated as toothache
Dental pain behaves differently. An abscess or an inflamed pulp tends to throb continuously, respond to heat and cold in a lingering way, worsen when you lie down at night, and stay put in one identifiable tooth. Trigeminal neuralgia is brief, shock-like, triggered by touch rather than temperature alone, and characteristically does not wake people from sleep.
That distinction is often missed. In one hospital series of people whose trigeminal neuralgia first presented as what sounded like toothache, 73% had irreversible dental treatment before anyone reached the right diagnosis, and 12.8% lost a tooth unnecessarily. Irish health service guidance acknowledges the trap directly: because the pain is felt in the jaw, teeth or gums, people go to the dentist rather than the GP, and diagnosis is delayed while more common explanations are worked through first. Dental assessment is sensible, because dental causes are far more likely. Extracting a structurally sound tooth to treat pain is not. If a first extraction brings no relief, that is the moment to ask your GP about nerve causes rather than authorise a second one.
Three causes, and why the MRI matters
Around 80% of cases are classical trigeminal neuralgia, where an artery or vein sits against the nerve root as it leaves the brainstem, wearing away its insulating sheath over years. Roughly 15% are secondary, caused by another condition, most commonly multiple sclerosis or, less often, a benign tumour pressing on the nerve. The remaining 5% are idiopathic: the pattern is textbook, the scan is clean. That 15% is why imaging is not optional. Some features raise the suspicion of a secondary cause: numbness in the face between attacks, both sides involved, hearing loss, onset before 40, or any other neurological sign. Mention these specifically to your GP, because they change the urgency of referral.
The Irish pathway, and the wait
Diagnosis is clinical. There is no blood test for it, and a careful history does most of the work, which is one reason to write down what triggers the pain and how long attacks last before you go in. From there the route runs to neurology, and for people who eventually need an operation, to Beaumont Hospital, which houses the national neurosurgical centre.
Capacity is the sticking point. The Neurological Alliance of Ireland, representing the more than 860,000 people here living with a neurological condition, counted 2,975 people on the neurology outpatient waiting list at University Hospital Galway alone in May 2026, and its pre-budget submission for 2027 seeks €2.2 million to strengthen neurology services nationwide. The useful consequence is that treatment usually starts in general practice rather than waiting on a consultant appointment, and it should.
Medicines: effective, and not to be taken casually
Carbamazepine is the first-line treatment, and the response is often so complete that it supports the diagnosis in itself. It is started low and built up gradually, aiming for the smallest dose that holds the pain down. Oxcarbazepine is the usual alternative when side effects make carbamazepine unworkable.
After 50, the monitoring matters as much as the prescription. Carbamazepine can drop your blood sodium, a risk that rises sharply if you also take a diuretic or have reduced kidney function, and low sodium shows up as confusion, unsteadiness and falls rather than as anything obviously chemical. It also affects blood counts and liver enzymes, so periodic bloods are standard, and drowsiness early on is a genuine falls risk. It is a powerful enzyme inducer too, so ask your community pharmacist to check it against your full medicines list before you start. Never stop it abruptly.
When tablets stop working
Medicines lose ground for a good number of people over time, and surgery becomes the sensible conversation rather than the desperate one. Microvascular decompression treats the cause directly by placing a cushion between the offending vessel and the nerve. It is open surgery under general anaesthetic, and it holds up: favourable outcomes of around 95.7% at one year and 74.2% at five to seven years. Stereotactic radiosurgery, delivered in Ireland on linear accelerator systems rather than the Gamma Knife described on American websites, is less invasive but fades faster: roughly 67% pain-free at three years, falling towards a third by around six years, with bothersome facial numbness in about 11%. Percutaneous procedures such as balloon compression sit between the two. Age alone should not decide which is offered to you.
What it costs, and what it takes out of you
If you hold a medical card, your medicines are covered. If you do not, the Drugs Payment Scheme caps what any household pays for approved prescribed medicines at €80 a month in 2026, with no means test. One quirk is worth knowing: the Long-Term Illness Scheme list, unchanged since 1975, does not include trigeminal neuralgia, so the condition itself brings no free medicines. Multiple sclerosis is on that list, so if your trigeminal neuralgia is secondary to MS, the medicines used to treat it are covered.
The wider toll is easy to underestimate. People avoid eating, talking and going out in cold weather, lose weight without meaning to, and become low and anxious in a way that is entirely proportionate to being ambushed by pain several times a day. Say that part out loud at your appointments. A scarf across the face on windy days, soft food at room temperature during a flare, and a written trigger diary make the days more tolerable and the medical conversation sharper.
Where to turn
Start with your GP, not your dentist, once the pattern looks like this one. Chronic Pain Ireland and the Irish Chronic Pain Association offer information and peer support for people living with long-term pain, and HSE Live is on 1800 700 700 for questions about services and entitlements. At Críonna Health we write these guides because the gap between a rare diagnosis and a well-informed conversation is usually just a few specific facts, held in the right order, at the right appointment.
This article is for general information and is not a substitute for individual medical advice. If facial pain is new, severe or changing, speak to your GP.
📷 Photo by Raymond Petrik on Unsplash
