📋 Key Information Summary
- Facial pain encompasses trigeminal neuralgia (TN), dental/periodontal causes, sinusitis, temporomandibular joint (TMJ) disorders, and atypical facial pain — each requiring a distinct diagnostic and management approach.
- Trigeminal neuralgia presents as sudden, severe, electric-shock-like pain in one or more divisions of the trigeminal nerve (V2/V3 most common); MRI brain with posterior fossa protocol is mandatory to exclude secondary causes such as multiple sclerosis or vascular compression.
- Carbamazepine (200–1200 mg/day) remains first-line pharmacotherapy for classical TN; oxcarbazepine (600–1800 mg/day) is an alternative with a more favourable side-effect profile.
- Dental and periodontal pathology is the most common cause of facial pain in general practice; a thorough odontological examination and dental panoramic radiograph are essential before attributing pain to other aetiologies.
- Acute sinusitis typically causes maxillary or frontal pressure pain worsening on bending forward; viral sinusitis is self-limiting (≤10 days), while bacterial sinusitis warrants amoxicillin 500 mg PO TDS for 5–7 days if symptoms persist >10 days or worsen after initial improvement.
- TMJ disorders present with pre-auricular pain, clicking/locking, and restricted mouth opening; conservative management (patient education, soft diet, simple analgesics, jaw exercises) is first-line for 80–90% of cases.
- Atypical facial pain (persistent idiopathic facial pain / burning mouth syndrome) is a diagnosis of exclusion — bilateral, poorly localised pain with no identifiable structural cause warrants a biopsychosocial approach with low-dose amitriptyline (10–25 mg nocte).
- Red flags requiring urgent referral include new-onset unilateral headache with Horner syndrome, progressive sensory loss, sudden vision changes, jaw claudication in patients >50 years (giant cell arteritis), and post-herpetic ophthalmic division involvement.
- Aboriginal and Torres Strait Islander Australians experience higher rates of dental disease and delayed access to specialist care; culturally safe engagement and facilitated access to oral health services are essential.
- Investigations should be tiered: dental panoramic X-ray and basic bloods (FBC, CRP, ESR) for most presentations; MRI brain with posterior fossa protocol for suspected TN; CT sinuses for refractory sinusitis; and temporal artery biopsy if giant cell arteritis is suspected.
- Post-herpetic neuralgia affecting the ophthalmic division (V1) of the trigeminal nerve requires early antiviral therapy (valaciclovir 1 g PO TDS for 7 days) within 72 hours of rash onset plus ophthalmology review to exclude keratitis.
- Neuropathic pain agents — gabapentin (300–3600 mg/day), pregabalin (150–600 mg/day), and low-dose tricyclic antidepressants — are second-line for TN and first-line for post-herpetic neuralgia and atypical facial pain.
- Surgical referral (microvascular decompression, percutaneous rhizotomy, or stereotactic radiosurgery) is indicated when TN is refractory to two adequate pharmacotherapy trials or medication side effects are intolerable.
Introduction & Australian Epidemiology
Facial pain is a common presenting complaint in Australian general practice, accounting for an estimated 2–4% of consultations involving pain. The differential diagnosis is broad, ranging from benign self-limiting conditions such as acute viral sinusitis to neurological emergencies such as giant cell arteritis or posterior fossa tumours compressing the trigeminal root.
The fifth cranial nerve (trigeminal nerve) provides sensory innervation to the face via three divisions: the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches. Pain may arise from neural, dental, sinus, musculoskeletal, or vascular structures, and overlapping presentations are common. A systematic approach to history, examination, and investigation is essential to avoid diagnostic delay and inappropriate treatment.
In Australia, trigeminal neuralgia has an estimated incidence of 12.6 per 100,000 person-years, with a peak incidence in the 60–70 year age group and a female-to-male ratio of approximately 3:2. Dental disease remains the most common cause of orofacial pain, with the Australian Institute of Health and Welfare (AIHW) reporting that approximately 32% of adults aged 15+ have untreated dental caries. TMJ disorders affect an estimated 6–12% of the Australian population, predominantly women aged 20–50 years. Sinusitis accounts for approximately 1.4 million general practice encounters annually in Australia.
This article provides a structured approach to the diagnosis and management of the four major categories of facial pain encountered in Australian primary care: trigeminal neuralgia, dental and periodontal causes, sinusitis and TMJ disorders, and atypical facial pain.
Trigeminal Neuralgia
Definition & Classification
Trigeminal neuralgia (TN) is defined by the International Headache Society (IHS) as a disorder characterised by recurrent unilateral brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve. It is classified as:
- Classical TN (TN1): Caused by vascular compression (typically the superior cerebellar artery) of the trigeminal root entry zone, with or without nerve demyelination.
- Secondary TN (TN2): Attributable to an identifiable underlying condition such as multiple sclerosis (MS) plaque, cerebellopontine angle tumour (schwannoma, meningioma), arteriovenous malformation, or brainstem lesion.
- Idiopathic TN: No identifiable cause on MRI.
Clinical Features
Key diagnostic features include:
- Paroxysmal, unilateral, electric-shock-like or stabbing pain lasting seconds to 2 minutes per episode.
- Distribution: V2 (maxillary) and V3 (mandibular) divisions most commonly affected; V1 (ophthalmic) involvement alone is uncommon and should prompt evaluation for secondary causes.
- Trigger zones: Light touch to the nasolabial fold, cheek, gums, or lips — eating, talking, brushing teeth, wind on the face.
- Refractory periods following paroxysms; pain-free intervals between clusters.
- No neurological deficit in classical TN; sensory loss in the trigeminal distribution suggests secondary TN.
Red flags — urgent MRI and neurology/neurosurgery referral: New-onset TN in a patient <40 years old (high risk of MS), associated neurological signs (hearing loss, diplopia, ataxia), bilateral symptoms, progressive sensory loss, or failure to respond to carbamazepine at adequate doses.
Pharmacological Management
Carbamazepine
Tegretol® · Teril® · Anticonvulsant / Sodium channel blocker
Adult dose
Start 100 mg PO BD, titrate by 100–200 mg every 3–7 days; maintenance 200–600 mg BD (max 1200 mg/day)
Paediatric dose
10–20 mg/kg/day in 2–3 divided doses (rare in children)
Renal adjustment
No adjustment required
Hepatic adjustment
Use with caution; contraindicated in severe hepatic impairment
Key monitoring
FBC (risk of agranulocytosis — ~1:125,000), LFTs, sodium; HLA-B*1502 testing in patients of Southeast Asian background before initiation
PBS status
✔ PBS General Benefit
Oxcarbazepine
Trileptal® · Anticonvulsant / Sodium channel blocker
Adult dose
Start 150 mg PO BD, titrate by 150 mg every week; maintenance 300–600 mg BD (max 1800 mg/day)
Renal adjustment
eGFR <30 mL/min: reduce dose by 50%
Key monitoring
Sodium (risk of hyponatraemia ~30% higher than carbamazepine); HLA-B*1502 testing; cross-reactivity ~25% with carbamazepine hypersensitivity
PBS status
⚕ PBS Authority Required
Gabapentin
Neurontin® · Gabapentin GH® · Anticonvulsant / Neuropathic pain agent
Adult dose
Start 300 mg PO nocte, titrate to 300 mg TDS then increase by 300 mg every 3–7 days; target 300–600 mg TDS (max 3600 mg/day)
Renal adjustment
eGFR 30–59: 200–700 mg BD; eGFR 15–29: 200–300 mg daily; eGFR <15: 100–300 mg daily
PBS status
✔ PBS General Benefit
Pregabalin
Lyrica® · Anticonvulsant / Neuropathic pain agent
Adult dose
Start 75 mg PO BD, titrate to 150 mg BD after 1 week; max 300 mg BD
Renal adjustment
eGFR 30–59: max 150 mg BD; eGFR 15–29: 25–75 mg daily; eGFR <15: 25 mg daily
PBS status
⚕ PBS Authority Required (neuropathic pain)
Lamotrigine
Lamictal® · Anticonvulsant (second-line TN)
Adult dose
Start 25 mg PO daily for 2 weeks, then 50 mg daily for 2 weeks, then increase by 50 mg every 1–2 weeks; target 100–200 mg BD
Key caution
Slow titration mandatory — risk of Stevens-Johnson syndrome. Dose halved if co-prescribed with valproate.
PBS status
✔ PBS General Benefit
Surgical Management
Surgical referral should be considered when pain is refractory to two adequate pharmacotherapy trials (adequate dose for ≥4 weeks) or when side effects are intolerable. Options include:
| Procedure | Mechanism | Efficacy (pain-free at 1 year) | Key Risks |
|---|---|---|---|
| Microvascular decompression (MVD) | Posterior fossa craniotomy; separation of offending vessel from trigeminal root | 75–80% | Hearing loss (1–2%), CSF leak, facial numbness (2–5%), stroke (<1%) |
| Percutaneous balloon compression rhizotomy | Balloon inflation at foramen ovale to compress Gasserian ganglion | 70–80% | Facial numbness (50–80%), masseter weakness, corneal numbness (V1) |
| Stereotactic radiosurgery (Gamma Knife) | Focused radiation to trigeminal root entry zone | 45–65% (delayed onset 1–3 months) | Facial numbness (20–30%), delayed recurrence higher |
| Percutaneous radiofrequency thermocoagulation | Thermal lesion of Gasserian ganglion fibres | 80–90% (short-term) | Facial numbness (50+%), higher recurrence rate |
Australian availability: Microvascular decompression and percutaneous procedures are available at major tertiary centres (e.g., Royal Melbourne Hospital, Royal North Shore Hospital, Royal Brisbane and Women's Hospital). Gamma Knife radiosurgery is available in Sydney, Melbourne, Brisbane, and Adelaide. MBS item numbers for neurosurgical procedures should be confirmed with the treating facility.
Dental & Periodontal Causes
Overview
Dental pathology is the most common cause of facial pain presenting to general practice. The AIHW reports that dental and oral health conditions account for over 83,000 hospitalisations per year in Australia, many of which are potentially preventable. General practitioners must be able to identify dental causes and facilitate timely referral, as delayed management can result in serious complications including Ludwig's angina and mediastinitis.
Common Dental & Periodontal Conditions
| Condition | Clinical Features | Initial GP Management | Referral |
|---|---|---|---|
| Dental caries (toothache) | Localised, throbbing pain; worse with hot/cold/sweet stimuli; may wake from sleep | Simple analgesia (ibuprofen 400 mg PO TDS + paracetamol 1 g PO QDS), dental referral | Dentist within 1–2 days |
| Dental abscess | Severe localised pain, swelling, fever, trismus; fluctuant swelling at apex of tooth | Amoxicillin 500 mg PO TDS (or clindamycin 300 mg PO QDS if penicillin allergy) + analgesia | Dentist or oral/maxillofacial surgeon same day; ED if airway compromise |
| Pericoronitis | Pain, swelling, trismus around partially erupted third molar; halitosis, dysphagia if severe | Chlorhexidine 0.2% mouth rinse, amoxicillin 500 mg PO TDS + metronidazole 400 mg PO TDS if severe, analgesia | Dentist/oral surgeon; ED if signs of fascial space infection |
| Periodontitis | Deep, dull aching pain; bleeding gums, loose teeth, receding gums; halitosis | Analgesia, dental referral for scaling and root planing | Dentist or periodontist |
| Cracked tooth syndrome | Brief, sharp pain on release of biting pressure; intermittent; difficult to localise | Analgesia; avoid hard foods on affected side; dental referral | Dentist within 1 week |
Amoxicillin
Amoxil® · Cilamox® · Penicillin antibiotic
Adult dose
500 mg PO TDS for 5–7 days
Paediatric dose
25–50 mg/kg/day PO in 3 divided doses (max 500 mg TDS)
Renal adjustment
eGFR 10–30: 500 mg BD; eGFR <10: 500 mg daily
PBS status
✔ PBS General Benefit
Clindamycin
Dalacin C® · Lincosamide antibiotic (penicillin allergy)
Adult dose
300 mg PO QDS for 5–7 days
Paediatric dose
8–25 mg/kg/day PO in 3–4 divided doses
Key caution
Risk of Clostridioides difficile colitis; counsel patient to stop if significant diarrhoea develops
PBS status
✔ PBS General Benefit
Metronidazole
Flagyl® · Metrogyl® · Nitroimidazole antibiotic
Adult dose
400 mg PO TDS for 5–7 days (often combined with amoxicillin for severe dental infections)
Key caution
Avoid alcohol (disulfiram-like reaction); metallic taste; avoid in first trimester of pregnancy
Renal adjustment
No adjustment required
PBS status
✔ PBS General Benefit
Odontogenic infection — emergency features: Airway compromise (tongue elevation, stridor, dysphagia), extensive floor-of-mouth swelling (Ludwig's angina), trismus limiting mouth opening to <2 cm, or signs of descending mediastinitis (chest pain, dyspnoea) require immediate ED referral and IV antibiotics.
Dental Access in Australia
Public dental services are available to eligible Australians (Health Care Card holders, Pensioner Concession Card holders, and children) through state/territory dental services. Wait times can be 12–24 months for general dental care. The Australian Government Chronic Disease Dental Scheme (CDDS) was replaced; current arrangements vary by state. GPs should facilitate urgent dental referrals through community health centres and hospital dental emergency departments for acute presentations. MBS items do not cover dental procedures in Australia.
Sinusitis & TMJ Disorders
Acute Sinusitis
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity lasting up to 4 weeks. The vast majority (90–98%) are viral in aetiology. Acute bacterial rhinosinusitis (ABRS) complicates 0.5–2% of viral upper respiratory infections.
Diagnostic Criteria for Acute Bacterial Sinusitis
Diagnosis of ABRS is clinical and requires at least ONE of:
- Persistent symptoms: nasal discharge (any colour) or facial pressure/pain lasting ≥10 days without improvement.
- Severe symptoms: purulent nasal discharge and facial pain/pressure for ≥3–4 consecutive days at the onset of illness.
- Double-sickening: worsening symptoms after initial improvement (suggests bacterial superinfection).
Management
| Scenario | Management | Notes |
|---|---|---|
| Viral sinusitis (<10 days) | Symptomatic: saline nasal irrigation, paracetamol/ibuprofen, intranasal corticosteroid (e.g., mometasone 200 mcg each nostril daily) | No antibiotics indicated |
| ABRS — first-line | Amoxicillin 500 mg PO TDS for 5–7 days (10 days if severe) | eTG Antibiotic recommendation; intranasal corticosteroid adjunctive |
| ABRS — allergy/second-line | Doxycycline 200 mg PO stat then 100 mg daily for 5 days, OR trimethoprim+sulfamethoxazole 160/800 mg PO BD for 5 days | Consider if penicillin allergy or no response at 48–72 hours |
| ABRS — refractory | Amoxicillin+clavulanate 875/125 mg PO BD, OR cefuroxime 500 mg PO BD, refer to ENT if no response | CT sinuses may be warranted; consider resistant organisms |
Doxycycline
Doryx® · Doxy® · Tetracycline antibiotic
Adult dose
200 mg PO stat then 100 mg daily for 5 days
Key caution
Avoid in pregnancy and children <8 years; take with food and water; photosensitivity risk
PBS status
✔ PBS General Benefit
Complicated sinusitis — refer urgently to ENT / ED: Periorbital swelling (preseptal or orbital cellulitis — especially in children), frontal bone osteomyelitis (Pott's puffy tumour), cavernous sinus thrombosis (bilateral periorbital oedema, proptosis, cranial nerve palsies), or intracranial abscess (headache, focal neurology, altered consciousness).
Temporomandibular Joint (TMJ) Disorders
TMJ disorders (TMD) encompass a group of musculoskeletal and neuromuscular conditions affecting the masticatory muscles, the TMJ, and associated structures. They are the most common cause of chronic orofacial pain after dental causes, affecting 6–12% of Australians, predominantly women aged 20–50 years.
Clinical Features
- Pre-auricular pain, often radiating to the ear, temple, or angle of the mandible.
- Worsened by chewing, yawning, or wide mouth opening.
- Clicking, popping, or crepitus on jaw movement.
- Limited mouth opening (<40 mm between upper and lower incisors; normal ≥40 mm).
- Jaw locking (open or closed position).
- Bruxism (nocturnal grinding) is a common contributing factor — often associated with stress, sleep disturbance.
Management Ladder for TMJ Disorders
1
Patient Education & Self-Care
Reassurance (most TMD is self-limiting), soft diet, avoid wide yawning/gum chewing, warm compresses, jaw relaxation exercises, stress management.
2
Pharmacotherapy
Paracetamol 1 g PO QDS ± ibuprofen 400 mg PO TDS for 1–2 weeks; short course of diazepam 2–5 mg PO nocte (max 1 week) for acute muscle spasm; intra-articular corticosteroid injection for refractory inflammatory flares (by oral medicine specialist or maxillofacial surgeon).
3
Occlusal Splint / Physiotherapy
Custom occlusal splint (Michigan splint) fabricated by dentist; referral to physiotherapist experienced in TMD (jaw exercises, manual therapy, dry needling).
4
Specialist Referral
Oral medicine specialist or maxillofacial surgeon for: refractory symptoms, internal derangement with locking, suspected ankylosis, or need for arthrocentesis/arthroscopy. Botulinum toxin injection (off-PBS for TMD) may be considered.
Avoid irreversible treatments: Occlusal adjustment (grinding of teeth) and irreversible orthodontic changes are NOT recommended for TMD. Evidence does not support their efficacy and they may worsen symptoms.
Atypical Facial Pain
Definition & Classification
Atypical facial pain encompasses several conditions now classified under the International Classification of Headache Disorders, 3rd edition (ICHD-3):
- Persistent idiopathic facial pain (PIFP) — formerly "atypical facial pain": Facial pain that does not fulfil the criteria for cranial neuralgias and is not attributable to another disorder. Pain is poorly localised, dull, aching, or burning; often daily and continuous; no autonomic features or physical signs.
- Burning mouth syndrome (BMS): Intraoral burning or dysaesthetic pain without identifiable dental or medical cause, lasting ≥2 hours per day for ≥3 months. Affects 1–5% of the general population, predominantly postmenopausal women.
- Persistent dentoalveolar pain disorder (PDAP): Pain in the teeth or alveolar process after endodontic treatment or extraction, with no identifiable cause. Previously termed "phantom tooth pain."
Diagnostic Approach
The diagnosis is one of exclusion. The following must be normal or excluded:
- Dental examination (including periapical radiographs) — by dentist.
- Neurological examination — normal cranial nerves, no trigeminal sensory deficit.
- TMJ examination — no clicking, limited opening, or joint pathology.
- Sinus examination — no congestion, discharge, or CT abnormalities.
- MRI brain — to exclude posterior fossa pathology, MS, or intracranial mass (especially if unilateral or neurological signs present).
- Blood tests — FBC, ESR, CRP, glucose, B12, folate, thyroid function (to exclude metabolic/systemic causes).
Management
Management requires a biopsychosocial approach with both pharmacological and non-pharmacological components:
Pharmacotherapy
Amitriptyline
Endep® · Tryptanol® · Tricyclic antidepressant
Adult dose
Start 5–10 mg PO nocte, titrate by 10 mg every 1–2 weeks; target 25–75 mg nocte
Key caution
Anticholinergic effects (dry mouth, constipation, urinary retention); cardiac conduction effects — avoid in significant cardiac disease; falls risk in elderly
Renal adjustment
No specific adjustment; use with caution
PBS status
✔ PBS General Benefit
Nortriptyline
Allegron® · Tricyclic antidepressant
Adult dose
Start 10–25 mg PO nocte, titrate to 50–100 mg nocte
Advantage
Fewer anticholinergic effects than amitriptyline; better tolerated in elderly
PBS status
✔ PBS General Benefit
Duloxetine
Cymbalta® · SNRI antidepressant
Adult dose
Start 30 mg PO daily for 1 week, then 60 mg PO daily; max 120 mg/day
Key caution
Nausea (transient); avoid in severe hepatic impairment; monitor blood pressure
PBS status
⚕ PBS Authority Required (neuropathic pain)
Non-Pharmacological Management
- Cognitive-behavioural therapy (CBT): Addresses pain catastrophising, avoidance behaviours, and comorbid anxiety/depression. Evidence supports its use in chronic orofacial pain.
- Stress management and relaxation techniques: Progressive muscle relaxation, mindfulness-based stress reduction.
- Physiotherapy: Especially if associated bruxism or myofascial component; jaw exercises, postural correction.
- Interdisciplinary pain management: Referral to a multidisciplinary pain clinic (e.g., through public hospital pain services) for refractory cases.
- Avoid unnecessary dental procedures: Repeated endodontic treatment or extractions in the absence of clear dental pathology worsens outcomes and should be discouraged.
Clinical pearl: Atypical facial pain often coexists with depression, anxiety, sleep disturbance, and somatisation. Screening for and treating these comorbidities is essential for effective pain management. Use validated tools such as the PHQ-9 and GAD-7.
Investigations
Investigations should be guided by clinical suspicion and tiered according to the most likely diagnosis:
Essential
Focused history & clinical examination
Including cranial nerve examination, dental examination, TMJ palpation, sinus percussion/transillumination, temporal artery palpation. Fundoscopy if headache component present.
GP Accessible
Dental panoramic radiograph (OPG)
MBS item 073 — available at dental practices and some radiology providers. Essential to exclude dental pathology before attributing pain to other causes.
GP Accessible
Blood tests
FBC, CRP, ESR (↑ in GCA, infection), HbA1c, B12, folate, TFTs. MBS items 65070 (FBC), 65065 (ESR), 66535 (CRP).
GP Accessible
CT sinuses (non-contrast)
MBS item 56300 — for refractory or recurrent sinusitis; NOT required for uncomplicated acute sinusitis. Evaluate for anatomical variants (septal deviation, concha bullosa), mucosal thickening, fluid levels.
Specialist / Referral
MRI brain with posterior fossa protocol
MBS item 63206 — MANDATORY for all patients with suspected trigeminal neuralgia to exclude secondary causes (MS plaques, CP angle tumour, vascular malformation). Thin-slice (1 mm) FIESTA/CISS sequences through the posterior fossa.
Specialist / Referral
Temporal artery biopsy
For suspected giant cell arteritis — ≥3 cm segment, within 1–2 weeks of starting corticosteroids. Available at major hospitals via vascular surgery or general surgery.
Specialist
CT/MR angiography (neurovascular protocol)
To evaluate vascular loop compressing the trigeminal root entry zone — adjunct to MRI in surgical planning for MVD.
Risk Stratification & Severity Assessment
Mild
Self-Limiting Conditions
Viral sinusitis (<10 days), simple dental caries, mild TMJ dysfunction, acute myofascial pain. No red flags, normal examination.
Setting: GP / Primary care — reassurance, symptomatic treatment, dental referral if indicated
Moderate
Requiring Active Treatment
Bacterial sinusitis, dental abscess (without airway compromise), established TN with good pharmacological response, moderate TMJ with functional limitation, persistent idiopathic facial pain.
Setting: GP with appropriate pharmacotherapy, specialist dental/oral medicine referral, physiotherapy for TMD
Severe
Urgent / Emergent
Odontogenic infection with airway compromise (Ludwig's angina), complicated sinusitis (orbital cellulitis, Pott's puffy tumour, cavernous sinus thrombosis), TN with suspected secondary cause, giant cell arteritis with visual symptoms, post-herpetic neuralgia with corneal involvement.
Setting: Emergency department / ENT / Neurosurgery / Ophthalmology — immediate referral
Post-Herpetic Neuralgia of the Trigeminal Nerve
Herpes zoster ophthalmicus (HZO) — reactivation of varicella-zoster virus in the ophthalmic division (V1) — accounts for approximately 10–20% of all herpes zoster cases and carries significant risk of ocular complications (keratitis in 20–70% of untreated cases) and post-herpetic neuralgia (PHN in 15–40% of patients, increasing with age).
Urgent ophthalmology referral required for ALL patients with herpes zoster involving the tip or side of the nose (Hutchinson's sign — nasociliary nerve involvement), as this strongly predicts ocular involvement. Slit-lamp examination should be performed within 1–2 days.
Acute Treatment
Valaciclovir
Valtrex® · Antiviral
Adult dose
1 g PO TDS for 7 days (start within 72 hours of rash onset; may be beneficial up to 7 days)
Renal adjustment
eGFR 30–49: 1 g PO BD; eGFR 10–29: 1 g PO daily; eGFR <10: 500 mg PO daily
PBS status
✔ PBS General Benefit
PHN Prevention & Treatment
- Prevention: Zostavax® (live vaccine — PBS-funded for adults ≥60 years) or Shingrix® (recombinant — recommended ≥50 years, currently funded for immunocompromised ≥18 years; self-funded for others).
- First-line PHN treatment: Gabapentin (titrate to 600 mg TDS) or pregabalin (titrate to 150 mg BD). Both are PBS-authority listed for neuropathic pain.
- Second-line: Nortriptyline 25–75 mg nocte or amitriptyline 10–75 mg nocte.
- Topical: Lidocaine 5% medicated plasters (Versatis®) — PBS Authority Required for PHN in patients ≥65 years or intolerant of systemic agents. Applied to affected area for up to 12 hours/day.
- Refractory PHN: Capsaicin 8% patch (Qutenza® — specialist application), referral to pain medicine specialist.
Special Populations
Pregnancy
Carbamazepine
Category D — teratogenic (neural tube defects ~1%). Use lowest effective dose; supplement with folate 5 mg/day. If TN treatment is essential, carbamazepine at the lowest effective dose is preferred over valproate.
Gabapentin / Pregabalin
Category B3 — use only if benefit outweighs risk; avoid in first trimester if possible.
Dental infection management
Amoxicillin is safe in pregnancy. Avoid metronidazole in first trimester. Paracetamol is preferred analgesic; ibuprofen is contraindicated after 30 weeks (premature ductus arteriosus closure).
Sinusitis
Saline irrigation and intranasal corticosteroids are safe. Amoxicillin is first-line. Avoid doxycycline and trimethoprim (teratogenic risk).
Paediatrics
Trigeminal neuralgia
Extremely rare in children. Consider MS, brain tumour, or vascular malformation as aetiology. MRI brain is mandatory. Refer to paediatric neurology.
Dental infections
Amoxicillin 25–50 mg/kg/day in 3 divided doses. Paediatric dental services available through state public dental programs (Child Dental Benefits Schedule for eligible families — up to 26 over 2 years).
Sinusitis
Children >3 days of worsening nasal discharge or fever — consider ABRS. Amoxicillin is first-line. Watch for orbital complications (preseptal cellulitis) — urgent ENT/ophthalmology referral.
Elderly
Carbamazepine
Start at lowest dose (50 mg BD); slower titration due to increased sensitivity and drug interactions (polypharmacy). Monitor sodium — risk of hyponatraemia.
Giant cell arteritis
Must be considered in any patient >50 years with new temporal/frontal headache, jaw claudication, visual symptoms, or scalp tenderness. ESR/CRP; immediate high-dose prednisolone 1 mg/kg/day; urgent rheumatology referral; temporal artery biopsy within 1–2 weeks.
Amitriptyline
Use with caution — Beers Criteria medication in elderly. Falls risk, cognitive effects, cardiac conduction effects. Prefer nortriptyline at lower doses (10–25 mg nocte).
Shingles vaccination
Shingrix® (recombinant zoster vaccine) is recommended for all adults ≥50 years and funded for immunocompromised ≥18 years. Reduces HZ incidence by 97% and PHN by 91%.
Renal Impairment
Gabapentin
Significant renal adjustment required (see drug card above). Common cause of neurotoxicity in CKD if not dose-adjusted.
Pregabalin
Dose reduction mandatory — see drug card. Dose based on eGFR.
Valaciclovir
Dose reduce for eGFR <50 mL/min — risk of neurotoxicity and crystalluria at standard doses in renal impairment.
Hepatic Impairment
Carbamazepine
Contraindicated in severe hepatic impairment. Monitor LFTs at baseline and periodically. Hepatotoxicity is rare but potentially fatal (risk ~1:100,000).
Duloxetine
Contraindicated in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment.
Immunocompromised
Herpes zoster
Higher risk of dissemination and complications. IV aciclovir (10 mg/kg TDS) for moderate-severe disease. Lower threshold for hospital admission. Shingrix® vaccine recommended ≥18 years (PBS-funded).
Dental infections
Higher risk of systemic sepsis. Broader antibiotic coverage may be needed (amoxicillin+clavulanate). Consider co-amoxiclav or clindamycin+gentamicin for neutropenic patients. Low threshold for IV antibiotics.
TN in young patients
TN in patients <40 years — high index of suspicion for MS. MRI brain with contrast is mandatory. Refer to neurology for further workup.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Australians experience a significantly higher burden of oral and facial pain conditions compared to the non-Indigenous population. The AIHW reports that Indigenous Australians are 1.6 times more likely to have untreated dental decay and 1.5 times more likely to report toothache. Access to dental and specialist services remains significantly lower in remote and very remote communities.
Quick Reference — Empirical Treatment Summary
Classical trigeminal neuralgia
Carbamazepine 200–600 mg PO BD
Ongoing — titrate to effect
Monitor FBC, sodium. MRI brain mandatory before diagnosis.
Dental abscess
Amoxicillin 500 mg PO TDS
5–7 days
Clindamycin 300 mg PO QDS if penicillin allergy. Dental referral essential.
Acute bacterial sinusitis
Amoxicillin 500 mg PO TDS
5–7 days
Add intranasal corticosteroid. Consider doxycycline if penicillin allergy.
TMJ disorder (acute flare)
Paracetamol 1 g QDS + Ibuprofen 400 mg TDS
1–2 weeks
Soft diet, warm compresses, jaw exercises. Short diazepam course if muscle spasm.
Herpes zoster ophthalmicus (acute)
Valaciclovir 1 g PO TDS
7 days
Start within 72h. Ophthalmology referral if Hutchinson's sign positive.
Post-herpetic neuralgia
Gabapentin (titrate to 600 mg TDS) or Pregabalin (titrate to 150 mg BD)
Ongoing — review at 8 weeks
PBS Authority Required. Lidocaine 5% patches as adjunct.
Persistent idiopathic facial pain
Amitriptyline 10–25 mg PO nocte
Trial ≥8 weeks at target dose
Biopsychosocial approach. CBT referral. Avoid unnecessary dental procedures.
Giant cell arteritis (suspected)
Prednisolone 1 mg/kg/day PO (max 80 mg)
Immediate — until rheumatology review
Urgent ESR/CRP, temporal artery biopsy. IV methylprednisolone if visual symptoms.
📚 References
- 1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
- 2. Bendtsen L, Zakrzewska JM, Abbott J, et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019;26(6):831–849.
- 3. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book). 9th ed. Melbourne: RACGP; 2016.
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