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B. Wayne Blount, MD, MPH. Trigeminal Neuralgia. “Tic Doloureau ”. 4.3 per 100,000 Slight female predominance : 1.74 t0 1 Peak incidence 60-70 y.o. Unusual before age 40 No racial prediliction. “Tic Doloureau ”. Higher incidence with M.S. & HTN

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Trigeminal Neuralgia

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B wayne blount md mph l.jpg

B. Wayne Blount, MD, MPH

Trigeminal Neuralgia


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“Tic Doloureau”

  • 4.3 per 100,000

  • Slight female predominance : 1.74 t0 1

  • Peak incidence 60-70 y.o.

  • Unusual before age 40

  • No racial prediliction


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“Tic Doloureau”

  • Higher incidence with M.S. & HTN

  • Spontaneous remission possible, BUT unusual

  • Most patients will have episodic attacks over many years


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Now 2 Types Are Identified

  • Classical

  • Symptomatic


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Classical Criteria

  • A. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve, & fulfilling criteria B & C.

  • B. Pain has at least 1 of the following characteristics:

    • 1. Intense, sharp, superficial, or stabbing

    • Precipitated from trigger zones or by trigger factors


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Classical Criteria

  • C. Attacks are stereotyped in

    the individual patient

  • D. No clinically evident neuro deficit

  • E. Not attributed to another disorder.


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Symptomatic Criteria

  • A. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, with or w/o persistence of pain between paroxysms, affecting 1 or more divisions of the trigeminal nerve, & fulfilling criteria B & C.

  • B. . Pain has at least 1 of the following characteristics:

    • 1. Intense, sharp, superficial, or stabbing

    • Precipitated from trigger zones or by trigger factors


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Symptomatic Criteria

  • C. Attacks are stereotyped

    in the individual patient

  • D. A causative lesion, other than vascular compression, has been demonstrated by special investigations &/or posterior fossa exploration.


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Pathophysiology


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? Pathophysiology ?

  • Demyelination of the trigeminal nerve, causing ectopic impulses and then ephaptic conduction

  • Vascular compression of the nerve root by aberrant or tortuous vessels

  • Compression by tumor

  • Amyloid

  • A-V malformation

  • Pons Infarct

  • Bony compression


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Diagnosis

  • Clinical

  • Consider in all patients with unilateral facial pain

  • Prompt Dx important as pain can be severe

  • Distinguish classical from symptomatic for RX purposes

  • Look for “red flags” of other diseases


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Red Flags

  • Abnormal Neuro exam

  • Abnormal oral, dental, or ear exam

  • Age < 40 yrs

  • Bilateral SXs

  • Dizziness or vertigo


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Red Flags

  • Hearing loss

  • Numbness

  • Pain lasting > 2 minutes

  • Pain outside of trigeminal distribution

  • Visual changes


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Diagnostic History

  • Very important

  • Recurrent, unilateral facial pain

  • Lasts seconds

  • May recur 100’s of times per day

  • Pain :

    • SevereStereotypical

    • SharpStabbing

    • SuperficialShock-like


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Diagnostic History

  • 1 or more of the nerve’s divisions

  • Trigger factors:

    • TalkingShaving

    • SmilingApplying make-up

    • ChewingWind

    • Teeth brushing

  • Age > 40 yrs.

  • Ask about other neuroSx

  • Asymptomatic time or not ?


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Physical Exam

  • Usually a normal exam

  • Useful for identifying abnormals that point to other DXs

  • HEENT, including TMJ & Masseter

  • Oral exam, including teeth & gums

  • Neuro exam

  • Check for trigger zones


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Diagnostic Testing

  • Generally Not helpful

  • MRI is the Test of Choice : ‘C’ Rec

  • ? Trigeminal reflex testing? Unclear usefulness & I would NOT do it


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Differential List

  • Cluster HADental Pain

  • Giant Cell ArteritisMigraine

  • Glossopharyngeal

  • NeuralgiaOtitis Media

  • Intracranial TumorSinusitis

  • Multiple SclerosisTMJ Syndrome

  • Postherpetic NeuralgiaParoxysmal Hemicrania


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Treatment

  • Medical

  • Surgical

  • No Behavioral, unless it becomes a cause of Chronic Pain


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Medical Treatment

  • Carbamazepine : ‘A’ Rec

  • NNT = 2.5 (For trigeminal Neuralgia)

  • NNH = 3.7 (For all diseases)

  • Some suggest it as a diagnostic trial

  • Doses range from 100 to 2,400 mg per day

  • Most respond to 200 to 800 mg per day

  • Immediate release (lasts about 6 hrs.)

  • Extended release (lasts about 12 hrs.)


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Medical Treatment

  • Carbamazepine Should be the initial Rx of choice for classical Trigeminal Neuralgia

  • If get no or only partial response to carbamazepine, add or substitute another pharmacologic agent:


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Medical Treatment

  • Other agents to try : ( Not listed in any order)

  • Baclofen : 10 m- 80 mg daily

  • Dilantin

  • Lamictal

  • Neurontin

  • Topamax

  • Klonopin

  • Orap

  • Depakene


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Medical Treatment

  • A recent Cochrane review said there was insufficient evidence to show benefit from non-epileptic agents in trigeminal neuralgia


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Follow-up

  • Achieve balance between pain and med side effects

  • Most want complete remission, which is possible and warranted

  • Can try a trial sans meds after “several” months symptom free (Think 4-6)


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Surgical Treatment

  • After failure of Pharm agents

  • Unusual

  • Recurrences occur for many

  • Both percutaneous & open techniques

    • Glycerol injectionBallon Compression

    • Radio RhizotomyGamma knife

    • Partial RhizotomyMicrovascular decompression


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Summary

  • 2 Types of trigeminal neuralgia

  • A clinical DX

  • Everyone gets a head & face MRI

  • Carbamazepine is the treatment of choice.


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References

  • Kraft, RM. Trigeminal Neuralgia. AFP. 2008;77:1291-1296.

  • Cochrane Collaboration

  • Haanpaa M, et al. Neuropathic Facial Pain. Suppl Clin Neurophysiol. 2006;58:153-170.


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References

  • Cruccu G, et al. Diagnosis of trigeminal neuralgia. In: Cruccu G, et al. Brainstem Function & Dysfunction. Amsterdam: Elsevier; 2006:171-186.

  • Wayne Blount


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