Headache
Trigeminal Neuralgia
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Trigeminal Neuralgia
, Tic Douloureux, Fothergill’s Disease
See Also
Trigeminal Nerve
Trigeminal Autonomic Cephalalgia
Cluster Headache
SUNCT Syndrome
Paroxysmal Hemicrania
Hemicrania Continua
History
John Fothergill first accurately described Trigeminal Neuralgia in 1773
Pearce (2003) J Neurol Neurosurg Psychiatry 74:1688 [PubMed]
Epidemiology
Incidence
: 15,000 new cases per year in U.S. (3.4 women or 5.9 men per 100,000 per year)
Incidence
in UK as high as 26.8 per 100,000, and 12.6 per 100,000 in Netherlands (but criteria vary)
Primary care physicians may see a few cases during their entire practice career
Incidence
in
Multiple Sclerosis
patients: 1-2%
Onset after age 40 years in 90% of cases
Mean age of onset 50 years old, with a peak at age 60 to 70 years
Incidence
increases to 45.2 per 100,000 in men over age 80 years old
More common in women by ratio of 2:1
Risk Factors
Multiple Sclerosis
(present in 2-4% of Trigeminal Neuralgia cases, RR 20)
Consider in younger patients (20-30 years old), especially with other neurologic involvement
Outside of
Multiple Sclerosis
, Trigeminal Neuralgia is typically a condition of older patients (see above)
Cerebrovascular Accident
Hypertension
in women
Pathophysiology
Related to
Trigeminal Nerve
demyelination
Demyelination due to compression from local structures (esp.
Superior Cerebellar Artery
)
Demyelinated fibers are more prone to ephaptic conduction
Light touch impulses transmit to nearby pain fibers
Most common site at cerebellopontine nerve root area
Effects all branches of the
Trigeminal Nerve
(Right side is more commonly involved)
Maxilla
ry branch is most commonly involved
Ophthalmic branch is least commonly involved
Symptoms
Facial pain in
Trigeminal Nerve
distribution
Recurrent paroxysms of sharp, stabbing or lancinating pain
Distribution
Maxilla
ry and mandibular branches of the
Trigeminal Nerve
(
CN 5
) are most commonly affected
Each attack is unilateral (may alternate sides in up to 3-5% of cases)
Characteristics
Lancinating or stabbing pain that is severe and intense
Electric shock type pain
Facial spasms related to paroxysms of pain (Tic Douloureux)
Timing
Each attack lasts for seconds to minutes
Attacks may occur as often as multiple times daily (as many as 100/day) or as infrequently as monthly
Attacks become more frequent and severe over time (and more refractory to medication)
Attacks are rare during sleep
Remissions of more than 6 months occur in 50% of patients
Triggers
Washing face
Tooth Brush
ing
Cold exposure
Chewing
Trigger Zone
s (pathognomonic for Trigeminal Neuralgia)
Small areas in the region of the nose and mouth
Light touch or other minimal stimulation in these zones triggers an attack
History
Red Flags suggesting secondary cause or alternative diagnosis
Abnormal findings on
Neurologic Exam
ination or on examination of head and neck (e.g. intracranial lesion)
Age under 40 years old
Pain lasts longer than 2 minutes
Bilateral pain during a single attack
Vision
change,
Hearing
change or
Vertigo
Findings suggestive of
Multiple Sclerosis
(e.g.
Ataxia
, unilateral
Vision
change)
Multiple Sclerosis
is often comorbid with Trigeminal Neuralgia
Examination
Evaluate for focal findings suggestive of a secondary cause or alternative diagnosis
Specific focal areas of examination (abnormalities suggest alternative diagnosis)
Temporomandibular Joint
Facial
Muscle Strength
and symmetry
Corneal Reflex
Trigeminal Nerve
Sensation
(normal in Trigeminal Neuralgia)
Trigger Zone
presence is pathognomonic for Trigeminal Neuralgia (see above)
Diagnosis
Classical Trigeminal Neuralgia (Primary Trigeminal Neuralgia)
Paroxysmal attacks localized to the
Trigeminal Nerve
Duration less than 2 minutes
Characteristics (at least one must be present)
Precipitated by triggers (e.g.
Trigger Zone
s)
Sharp, stabbing, intense pain
Attacks are stereotypical for individual patients
No neurologic clinical findings or other findings suggesting as secondary condition
Diagnosis
Atypical or Symptomatic Trigeminal Neuralgia (Type II or Trigeminal Neuralgia with concomitant pain)
May be secondary to other conditions (consider secondary cause evaluation)
Similar to classical Trigeminal Neuralgia with the following EXCEPTIONS
Aching, lower level pain may persist between episodes for up to 50% of the time
Differential Diagnosis
Cluster Headache
or other
Migraine Headache
Postherpetic Neuralgia
Glossopharyngeal Neuralgia
Dental Infection
or
Dental Caries
Temporomandibular Joint Syndrome
Acoustic Neuroma
Multiple Sclerosis
(may be comorbid)
Vascular Malformation
Imaging
Head MRI
Indications
Indicated in most cases of Trigeminal Neuralgia at onset
Intracranial lesions are present in up to 10% of cases
Diagnostics
Trigeminal reflex testing (via EMG testing)
Differentiates classic from symptomatic Trigeminal Neuralgia with high efficacy
Cruccu (2006) Neurology 66:139-41 [PubMed]
Management
Gene
ral
Neurology referral
Evaluate for comorbid conditions (
Multiple Sclerosis
, Intracranial Lesions)
Management
Seizure
medications (examples)
Carbamazepine
(Most studied)
Typical effective dosage: 200-800 mg/day divided 2-3 times daily
Longterm failure rate approches 50% after 5-10 years of continuous use
Oxcarbazepine
(
Trileptal
)
Effective for pain reduction and fewer side effects than
Carbamazepine
, but less effective in the longterm
Baclofen
(
Lioresal
)
Typical effective doses: 10-80 mg/day
Consider in
Multiple Sclerosis
patients with Trigeminal Neuralgia
Agents with unknown effectiveness (inadequate studies as of 2016)
Phenytoin
(
Dilantin
)
Gabapentin
(
Neurontin
)
Topiramate
(
Topamax
)
Lamotrigine
(
Lamictal
)
References
Delzell (1999) Arch Fam Med 8(3): 264-8 [PubMed]
Management
Symptomatic therapies
Topical
Capsaicin
Intranasal
Lidocaine
(for second
Trigeminal Nerve
branch)
Acupuncture
is ineffective in Trigeminal Neuralgia
Millan-Guerrero (2006) Headache 46(3): 532 [PubMed]
Management
Surgical
Percutaneous Methods (non-invasive but short lasting)
Glycerol
injection
Gamma Knife
Radiofrequency thermocoagulation
Effective, but risk of facial numbness and
Cornea
l insensitivity
Oturai (1996) Clin J Pain 12(4):311-5 [PubMed]
Invasive Surgical Techniques (posterior fossa exploration)
Microvascular decompression (Most effective, duration of 10 years in 70% of cases)
Preferred over sterotactic radiosurgery
Risk of unilateral
Hearing Loss
in 5% of cases
Hai (2006) Neurol India 54(1):53-6 [PubMed]
Tronnier (2001) Neurosurgery 48(6): 1261-8 [PubMed]
Complications
Major Depression
and
Suicidality
(due to severity of pain and incapacity)
Course
Remission is typical (>50% of patients) for at least 6 months
References
Krafft (2008) Am Fam Physician 77(9):1291-6 [PubMed]
Kumar (1998) Postgrad Med 104(4):149-56 [PubMed]
Scrivani (2005) Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100(5):527-38 [PubMed]
Zakrzewska (2016) Am Fam Physician 94(2): 133-5 [PubMed]
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