A 43-year-old female presented with an 11-month history of monthly intermittent left-sided facial pain. Each episode began within a day or two of menstruation and initially involved sharp, paroxysmal, electric-shock-like pains in her left cheek, lasting seconds to minutes. These symptoms were exacerbated by talking, facial touch, eating, or nasal breathing, classic triggers associated with trigeminal neuralgia. Within an hour, the pain evolved into a pounding, constant ache radiating across her left cheek, jaw, orbital, and temporal areas, often accompanied by nausea, photophobia, and phonophobia. The pain was severe for three days and resolved completely in about one week. She had no history of migraine or aura, but had a family history of migraine without aura (mother). Her past medical history included mild anxiety and depression for which she was on dosulepin 25 mg nightly.
Physical and neurological examinations were normal. MRI brain scans performed twice showed no abnormalities, and magnetic resonance angiography revealed no vascular compression of cranial nerves. The patient was initially treated with carbamazepine (500 mg BID) for left facial pain. The patient was admitted to her local hospital during a severe attack, at which point gabapentin was initiated and escalated to 300 mg three times daily, with plans to taper carbamazepine if effective. Around 11 months after symptom onset, she was referred to our headache clinic, where we have followed her for the past 15 months. Prior to specialist consultation, the patient had tried various OTC analgesic preparations to treat the acute attacks, but they had been ineffective. Initial treatments with rizatriptan 10 mg (once daily during attacks) and zolmitriptan nasal spray (used in two consecutive attacks) also failed to provide relief.