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Trigeminal Neuralgia

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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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tic doloureau
“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 doloureau3
“Tic Doloureau”
  • Higher incidence with M.S. & HTN
  • Spontaneous remission possible, BUT unusual
  • Most patients will have episodic attacks over many years
now 2 types are identified
Now 2 Types Are Identified
  • Classical
  • Symptomatic
classical criteria
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
classical criteria6
Classical Criteria
  • C. Attacks are stereotyped in

the individual patient

  • D. No clinically evident neuro deficit
  • E. Not attributed to another disorder.
symptomatic criteria
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
symptomatic criteria8
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.
pathophysiology10
? 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
diagnosis
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
red flags
Red Flags
  • Abnormal Neuro exam
  • Abnormal oral, dental, or ear exam
  • Age < 40 yrs
  • Bilateral SXs
  • Dizziness or vertigo
red flags13
Red Flags
  • Hearing loss
  • Numbness
  • Pain lasting > 2 minutes
  • Pain outside of trigeminal distribution
  • Visual changes
diagnostic history
Diagnostic History
  • Very important
  • Recurrent, unilateral facial pain
  • Lasts seconds
  • May recur 100’s of times per day
  • Pain :
    • Severe Stereotypical
    • Sharp Stabbing
    • Superficial Shock-like
diagnostic history15
Diagnostic History
  • 1 or more of the nerve’s divisions
  • Trigger factors:
    • Talking Shaving
    • Smiling Applying make-up
    • Chewing Wind
    • Teeth brushing
  • Age > 40 yrs.
  • Ask about other neuroSx
  • Asymptomatic time or not ?
physical exam
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
diagnostic testing
Diagnostic Testing
  • Generally Not helpful
  • MRI is the Test of Choice : ‘C’ Rec
  • ? Trigeminal reflex testing? Unclear usefulness & I would NOT do it
differential list
Differential List
  • Cluster HA Dental Pain
  • Giant Cell Arteritis Migraine
  • Glossopharyngeal
  • Neuralgia Otitis Media
  • Intracranial Tumor Sinusitis
  • Multiple Sclerosis TMJ Syndrome
  • Postherpetic Neuralgia Paroxysmal Hemicrania
treatment
Treatment
  • Medical
  • Surgical
  • No Behavioral, unless it becomes a cause of Chronic Pain
medical treatment
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.)
medical treatment21
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:
medical treatment22
Medical Treatment
  • Other agents to try : ( Not listed in any order)
  • Baclofen : 10 m- 80 mg daily
  • Dilantin
  • Lamictal
  • Neurontin
  • Topamax
  • Klonopin
  • Orap
  • Depakene
medical treatment23
Medical Treatment
  • A recent Cochrane review said there was insufficient evidence to show benefit from non-epileptic agents in trigeminal neuralgia
follow up
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)
surgical treatment
Surgical Treatment
  • After failure of Pharm agents
  • Unusual
  • Recurrences occur for many
  • Both percutaneous & open techniques
    • Glycerol injection Ballon Compression
    • Radio Rhizotomy Gamma knife
    • Partial Rhizotomy Microvascular decompression
summary
Summary
  • 2 Types of trigeminal neuralgia
  • A clinical DX
  • Everyone gets a head & face MRI
  • Carbamazepine is the treatment of choice.
references
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.
references28
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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