When tongue pain is trigeminal neuralgia: illustrative cases.

BACKGROUND

Trigeminal neuralgia (TN) classically presents with paroxysmal facial pain in the V2 or V3 distributions. Rarely, symptoms localize to the anterior tongue, mimicking peripheral lingual nerve pathology or glossopharyngeal neuralgia.

OBSERVATIONS: Two older women presented with refractory right-sided tongue pain. Case 1 was an 80-year-old woman with sublingual pain evolving from shock-like paroxysms to continuous burning, with no neurovascular compression (NVC) demonstrated on preoperative MRI. Case 2 was a 71-year-old woman who underwent Gamma Knife radiosurgery and lingual nerve exploration for presumed peripheral pathology without relief, despite MRI showing venous loops at the root entry zone. Both had NVC at the trigeminal root confirmed intraoperatively and achieved complete pain resolution after microvascular decompression.

LESSONS: TN can present as isolated tongue pain due to proximal pathology at the trigeminal root. Misattribution to peripheral lingual nerve disease can lead to unnecessary interventions. Negative MRI findings do not exclude the diagnosis when clinical features are compelling. https://thejns.org/doi/10.3171/CASE26480.