Trigeminal Neuralgia — FRCA Final MCQ

Instant feedback + full explanation. One question, done properly.

ModeratePain MedicineTrigeminal NeuralgiaFRCA Final

A 55-year-old man with trigeminal neuralgia affecting the V2 and V3 distributions continues to have severe lancinating facial pain despite an appropriately titrated maximum tolerated dose of carbamazepine. He is being managed in a non-specialist setting. According to NICE CG173, what is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Seek expert advice and refer early to a specialist pain service

Explanation lettering: C = shown as B · B = shown as C · E = shown as D · D = shown as E

NICE CG173 offers carbamazepine as initial treatment for trigeminal neuralgia and, when it is ineffective, not tolerated or contraindicated, advises seeking expert advice and considering early referral to a specialist pain or condition-specific service. It does not name an automatic second-line drug. Amitriptyline, gabapentin and pregabalin (options A, C, D) belong to the general neuropathic pain pathway, which expressly excludes trigeminal neuralgia, so adding or switching to them is not supported. Regular oral morphine (E) is among the drugs CG173 says should not be started in non-specialist settings unless a specialist advises it, and opioids are ineffective for paroxysmal trigeminal pain. Oxcarbazepine is frequently used, but only under specialist direction; specialists also consider lamotrigine, baclofen and neurosurgical options such as microvascular decompression, percutaneous procedures or stereotactic radiosurgery, reinforcing the need for referral.

Reference: National Institute for Health and Care Excellence. CG173 Neuropathic pain in adults: pharmacological management in non-specialist settings — Recommendations 1.1.11–1.1.14. Published 2013, last updated 2020. https://www.nice.org.uk/guidance/cg173/chapter/recommendations