Multiple sclerosis Patients with multiple sclerosis often have typical trigeminal neuralgia or similar atypical facial pain. The number of patients with multiple sclerosis in a reported series of trigeminal neuralgia patients is susceptible to selection bias. The literature suggests that less than 0.5% of patients with trigeminal neuralgia have multiple sclerosis in combination. Women younger than 45 years of age are most likely to suffer from facial twitching due to multiple sclerosis. The diagnosis requires clear temporal and spatial multiple neurological damage. If a patient has only symptoms of trigeminal neuralgia, the diagnosis of multiple sclerosis is not recommended, regardless of age. Tumors Tumor-induced trigeminal neuralgia is uncommon, whereas fixed pain combined with sensory deficit diagnosed as atypical facial pain is common. Only a small percentage of patients with trigeminal neuralgia have small, benign tumors. Common tumors include meningiomas, nerve sheath tumors, or lipomas. Primary tumors of the trigeminal nerve or tumor compression in and around the foraminal region of Meckel, s are rarely typical of trigeminal neuralgia. They often result in persistent aching pain with combined sensory loss and other cranial nerve involvement. The reasons for the delayed diagnosis at the beginning of this case include: (1) pain involves several disciplines, and the physician’s knowledge of the relevant disciplines is lacking, so he or she did not pay attention to the small amount of nasal bleeding that the patient often had; (2) in the absence of a clear diagnosis, the clinical judgment was influenced after the trigeminal nerve block treatment, because the nociception in the corresponding distribution area would be reduced after the trigeminal nerve block, masking the hyperalgesia caused by the nasopharyngeal cancer damaging the trigeminal nerve. Neuralgia after herpes zoster and herpes infection Herpes zoster can involve the trigeminal nerve and cause painful neuropathy. Pain in the face or ear often precedes the onset of blisters, making diagnosis difficult around 1 day after onset. If the pain persists after the onset of the rash, the diagnosis of postherpetic neuralgia can be made. Ramsay-Hunt syndrome, which is secondary to geniculate transganglionic herpesvirus infection, presents with blistering in the ear and pain in the inner ear and posterior pharyngeal wall. Intermediate nerve (geniculate nerve) pain Intermediate neuralgia is a rare pain syndrome that was discovered by Clark and Taylor in 1909 and has been rarely reported since. The syndrome is similar to trigeminal neuralgia in all respects, except for the site of attack, and is described here. Patients often complain of discharge-like pain in the distribution of the somatosensory branches of the median nerve. The pathogenesis of median neuralgia is presumed to be similar to that of trigeminal neuralgia, which can be caused by transverse vascular compression at the central-peripheral myelin junction of the median nerve, a few millimeters lateral to the pontine brain. Symptoms and signs Patients complain of deep paroxysmal stabbing or discharge-like pain in the ear, which can be triggered by nontoxic stimulation in the ear canal, swallowing, or speech. Interictal periods are painless, nerve defects are rare, and attacks are often unilateral. Some patients have salivation, micturition, tinnitus, and vertigo during the attacks, which may suggest a connection between the middle nerve and other nociceptors or involvement of the VII and VIII cranial nerve components. Patients with pain in the trigeminal nerve distribution rarely have a combination of intermediate neuralgia. Treatment Intermediate neuralgia is treated in the same way as the medical treatment of trigeminal neuralgia. When the pain is not controlled by medication, surgical means may be considered. Local anesthesia to block intermediate neuralgia is not possible, but the effect of the intermediate nerve on them can be reduced by anesthetizing the linguopharyngeal and trigeminal nerves. After failure of medical treatment, suboccipital craniectomy of the median nerve may be considered for exploration. If vascular invasion is found, it can be removed; if not, the median nerve can be partially severed. This method is highly likely to provide lasting relief of pain; if this method fails, only the middle portion of the descending branch of the trigeminal nerve bundle can be severed.