“I get sudden electric-shock pains in my face when I brush my teeth or feel a breeze — it’s unbearable”

PAROXYSMS of sudden, severe, UNILATERAL, STABBING/ELECTRIC-SHOCK facial pain lasting seconds in a trigeminal-nerve division (commonly maxillary/mandibular), TRIGGERED by innocuous stimuli to "trigger zones" (light touch, chewing, tooth-brushing, washing the face, cold breeze, talking) with pain-free/refractory intervals, is the classic picture of TRIGEMINAL NEURALGIA. Distinguish it from dental pain (usually continuous/throbbing, not touch-triggered paroxysms — patients often see a dentist first), cluster headache (longer, orbital, autonomic), migraine, TMJ pain, sinusitis and giant cell arteritis. Critically, screen the RED FLAGS suggesting a SECONDARY cause (an underlying lesion such as multiple sclerosis or a compressive vascular/tumour lesion): younger age at onset (often quoted as under 40), BILATERAL symptoms, facial SENSORY LOSS/numbness, other cranial-nerve or neurological signs, deafness, MS/optic features, or atypical continuous pain — which warrant neurology referral and MRI (the cranial nerve examination is done face to face); classic unilateral TN in an older patient with a normal neuro exam is usually primary, but the screen must be explicit. Treat first-line with CARBAMAZEPINE (NICE CG173, 2013; BNF: start 100 mg once or twice daily, increase gradually to the lowest effective dose), with baseline FBC, U&E (sodium) and LFTs and HLA-B*1502 testing first in people of Han Chinese or Thai origin, counselling side-effects and monitoring — dizziness/ataxia, HYPONATRAEMIA, blood dyscrasias, LFT derangement, rash (including rare serious SJS/TEN — stop and seek help), many drug interactions (enzyme inducer), and contraception only if still needed (CoSRH) — with alternatives (oxcarbazepine, lamotrigine, gabapentin, baclofen) if intolerant/refractory, guided by specialist advice as NICE CG173 advises. Acknowledge the major quality-of-life impact (fear of eating/talking/washing, weight loss, low mood — ask directly about suicidal thoughts, NICE NG225) and refer to neurology for confirmation, red flags (with MRI), refractory pain, or surgical options (e.g. microvascular decompression). The hidden agenda is fear and exhaustion (and possible dental bouncing); the skill is confident pattern recognition, first-line carbamazepine with proper counselling, the explicit red-flag screen, and referral.