Trigeminal Neuralgia

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Trigeminal Neuralgia

• B. Wayne Blount, MD, MPH

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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 lt 40 yrs
• Bilateral SXs
• Dizziness or vertigo

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Red Flags

• Hearing loss
• Numbness
• Pain lasting gt 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 100s of times per day
• Pain
• Severe Stereotypical
• Sharp Stabbing
• Superficial Shock-like

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Diagnostic History

• 1 or more of the nerves divisions
• Trigger factors
• Talking Shaving
• Smiling Applying make-up
• Chewing Wind
• Teeth brushing
• Age gt 40 yrs.
• Ask about other neuro Sx
• 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 HA Dental Pain
• Giant Cell Arteritis Migraine
• Glossopharyngeal
• Neuralgia Otitis Media
• Intracranial Tumor Sinusitis
• Multiple Sclerosis TMJ Syndrome
• Postherpetic Neuralgia Paroxysmal
  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 injection Ballon Compression
• Radio Rhizotomy Gamma knife
• Partial Rhizotomy Microvascular
  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.
  2008771291-1296.
• Cochrane Collaboration
• Haanpaa M, et al. Neuropathic Facial Pain. Suppl
  Clin Neurophysiol. 200658153-170.

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References

• Cruccu G, et al. Diagnosis of trigeminal
  neuralgia. In Cruccu G, et al. Brainstem
  Function Dysfunction. Amsterdam Elsevier
  2006171-186.
• Wayne Blount