Neuro By MPMEP*

TRIGEMINAL NEURALGIA
Trigeminal neuralgia is characterised by paroxysmal
attacks of severe, short, sharp, stabbing pain affecting one
or more divisions of the trigeminal nerve. The pain involves
the second or third divisions more often than the first; it
rarely occurs bilaterally and never simultaneously on each
side,occasionally more than one division is involved.
Paroxysmal attacks last for several days or weeks; they
are often superimposed on a more constant ache.
When the attacks.settle, the patient may remain pain free
for many months.
Chewing, speaking, washing the face, tooth-brushing, cold
winds, or touching a specific "trigger spot, e-g. upper lip or
gum, may all precipitate an attack of pain.
PREVALENCE & INCIDENCE :-
Trigeminal neuralgia more commonly affects females and
patients over 50 years of age.
AETIOLOGY :-
Trigeminal pain may be symptomatic of disorders which
affect the nerve root or its entry zone.
Root or root entry zone compression
- arterial vessels often abut and sometimes clearly indent
the trigeminal nerve root at the entry-zone into the pons,
causing ephaptic transmission (short circuiting).
Tumours of the cerebellopontine angle lying against the V
nerve roots, e.g. meningioma, epidermoid cyst, frequently
present with trigeminal pain.
Demyelination-such a lesion in the pons should be
considered in a 'young' person with trigeminal neuralgia.
Trigger spots are rare. Remission occurs infrequently and
the
response to drug treatment is poor.
In some patients the cause remains unexplained, as do the
long periods of remission.
INVESTIGATIONS :-
MR scan to exclude a cerebello-pontine angle lesion or
demyelination.
MANAGEMENT :-
Drug therapy
CARBAMAZEPINE proves effective in most patients (and
helps confirm the diagnosis).
Provided toxicity does not become troublesome, i.e.
drowsiness, ataxia, the dosage is increased until pain relief
occurs (600-1600 mg'day). When remission is established,
drug treatment can be discontinued.
If pain control is limited, other drugs-BACLOFEN,
LAMOTRIGINE, GABAPENTIN, PHENYTOIN-may benefit.
Persistence of pain on full drug dosage or an intolerance of
the drugs, indicates the need for more radical measures.
The choice lies between a range of lesional techniques,
which all produce some damage to the trigeminal nerve
with some consequent sensory loss, or microvascular
decompression, which does not damage the nerve but has
the risks associated with open neurosurgery.