Snapshot A 54-year-old female presents with severe, stabbing pain on her left mandible. The pain lasts a few seconds and is triggered by brushing her teeth or chewing food. The pain episodes lasts a few seconds and occur 20 times per day. She denies any recent trauma or dental procedures. Over the counter simple analgesics do not improve the pain. On physical exam, touching the mandibular region reproduces the pain. Neurological exam is otherwise normal. Introduction Severe, sharp, stabbing pain in one or more trigeminal nerve (CN V) divisions onset and termination is abrupt commonly involving V2 and V3 branches of CN V Epidemiology More commong in women Age: > 50-years-old May be a manifestation of multiple sclerosis Pathophysiology Most commonly due to neurovascular compression involving the superior cerebellar artery Compression can also be due to malignancy, amyloidosis, or plaque (e.g., multiple sclerosis) Presentation Symptoms sharp, shock-like pain in one more more CN V divisions typically unilateral usually lasts seconds long can be triggered by mechanical stimuli e.g., brushing teeth, smiling, chewing Evaluation Clinical diagnosis Differential Dental pain Cluster headache Temporomandibular joint (TMJ) pain Glossopharyngeal neuralgia Treatment Medical carbamazepine first-line oxcarbazepine Surgical - for refractory cases microvascular decompression rhizotomy radiosurgery Prognosis, Prevention, and Complications Complications issues with eating and drinking