Neuralgia is pain in a nerve pathway. Generally, neuralgia isn’t an illness in its own right, but a symptom of injury or a particular disorder. In many cases, the cause of the pain is not known. Older people are most susceptible, but people of any age can be affected.

Almost everyone will experience mild neuralgia at some point, but these bouts are usually temporary and tend to ease by themselves within a few days. Some types of neuralgia are longer lasting, debilitating and so agonising that a person’s quality of life is severely reduced.

Trigeminal neuralgia, a condition that usually affects one side of the face only, is said to be one of the most painful medical conditions. Neuralgia can be managed with medication and physical therapy. Surgery is an option in some resistant cases.

Trigeminal neuralgia

This is the most common type of neuralgia, also known as tic douloureux. The trigeminal nerve supplies various areas of the face, including the cheeks and jaw. Trigeminal neuralgia is characterised by sudden jolts of shooting pain that usually affect one side of the face only. Sometimes, a person experiences pain on both sides of the face, though at alternating times. The pain may be severe enough to cause spasms of the facial muscles (tic).

Trigeminal neuralgia turns everyday activities, such as toothbrushing or shaving, into agonising events. Even a gentle breeze blowing on the face can trigger pain. Known causes include multiple sclerosis or tumours pressing against the nerve. Women over the age of 50 years are most commonly affected.

Occipital neuralgia

Irritation of the main nerve that runs from the back of the skull can cause occipital neuralgia. This type of headache or pain is dull, throbbing and localised to the back of the head. The pain can sometimes include the forehead. It is suspected that tense muscles or ligaments may press against the nerve, causing irritation, inflammation and subsequent pain. Other causes may include viral infection, trauma to the neck or bad posture.

Occipital neuralgia is a rare neurological condition that involves shooting, shocking, throbbing, burning, or aching pain and headache that generally starts at the base of the head and spreads along the scalp on one or both sides of the head. It involves the occipital nerves, which run from the area where the spinal column meets the neck, up to the scalp at the back of the head.  

Pain is typically felt in the:

• Upper neck
• Back of the head
• Behind the eyes and ears (usually on one side of the head)
• Scalp
• Forehead

The pain usually begins in the neck and then spreads upward. Some people describe the pain as migraine-like. The scalp may become tender and extremely sensitive to the point where a light touch can cause severe pain (allodynia). Causes of occipital neuralgia include injury, pinched nerve, overly tight neck muscles, nerve compression, disc disease, or infection and inflammation.

Diagnosis of occipital neuralgia is usually done through a physical and neurological exam, along with diagnostic imaging. A nerve block (in which a local anesthetic and steroid drug are injected into the area around the nerve) may help with diagnosis. Treatment options include medications, steroid injections, heat, and surgery.  

Pudendal neuralgia occurs when the pudendal nerve is injured, irritated, or compressed. Symptoms include burning pain (often unilateral), tingling, or numbness in any of the following areas: buttocks, genitals, or perineum (area between the buttocks and genitals). Symptoms are typically present when a person is sitting but often go away when the person is standing or lying down. The pain tends to increase as the day progresses. Additional symptoms include pain during sex and needing to urinate frequently and/or urgently.

Damage to the pudendal nerve can result from surgical procedures, childbirth, trauma, spasms of the pelvic floor muscles, or tumors. Pudendal neuralgia may also result from certain infections (such as herpes simplex infections) or certain activities (such as cycling and squatting exercises).

There are no imaging studies that diagnose pudendal neuralgia; however, MRI and CT may help to exclude other causes of the pain. Physical therapy is often the first line of treatment.

Nerve inflammation (neuritis) can trigger neuralgia. Causes of neuritis include:

• Shingles – inflammation of a nerve, caused by infection with the herpes virus. This common type of neuralgia is known as post-herpetic neuralgia. The pain may remain long after the shingles rash has disappeared, particularly in areas of the face
• Infection – the nerve can be irritated by nearby infection, such as a tooth abscess
• Pressure or injury – broken bones, slipped vertebral discs (sciatica) or certain tumours can press and irritate a nerve
• Syphilis – in its advanced stages, this sexually transmitted disease affects the functioning of the nervous system.

Symptoms of neuralgia can include:

• Localised pain
• The area may be excruciatingly sensitive to touch, and any pressure is felt as pain
• The pain can be sharp or burning, depending on the affected nerve
• The affected area is still functional
• The muscles may spasm.

There are no specific tests for neuralgia. Diagnosis relies more on ruling out other possible causes for the pain. Tests may include:

• Neurological examination – to determine specific areas of pain
• Dental examination – to check for abscesses that may be irritating nearby nerves
• Blood tests – to check for infection
• X-rays – to see if the affected nerves are being compressed.

Treatment options include:

• Treatment for the underlying cause – such as dental treatment and antibiotics for a tooth abscess, or surgery to remove bone pressing against the nerve
• Pain-relieving medications – such as aspirin or codeine
• Anticonvulsant medications – to treat the pain and muscle spasms associated with trigeminal neuralgia
• Antidepressants – to help relieve pain in some cases
• Surgery – to desensitise the nerve and block pain messages
• Physical therapy – such as physiotherapy and osteopathy
• Alternative therapies – such as acupuncture, hypnosis and meditation.