TRIGEMINAL NEURALGIA –

A DEBILITATING FACIAL PAIN

dr. Hermilawaty Abubakar, SpKFR

Instalasi Rehabilitasi Medik RSUD Undata

Trigeminal Neuralgia (TN)
“ S u dd e n us ua l l y u ni l atera l s eve re , br i ef,
sta b bi n g , re c u r re nt e pi s o d es o f p a i n i n t he
d i s tr i b ut i o n o f o ne o r mo re bra n c he s o f t he
t r i g em i n a l n e r v e ”
(The International Association for The Study of Pain (IASP))
Trigeminal Neuralgia (TN)
“A di s o rder c h a ra c ter i ze d by re cu r re nt u ni l atera l
b r i ef el e c t r i c s ho c k - l i ke p a i n , a b r u pt i n o ns et
a n d ter mi na ti o n, l i mi te d to t h e d i s tr i b uti o n o f
o ne o r mo re d i v i s i o n s o f t he tr i g em i n a l ner ve
a n d t r i g ge re d by i n n o c u o u s s t i m u l i ”
(The International Classification of Headache Disorders)
Trigeminal Neuralgia (TN)
• The most common diseases of cranial nerves
• Most frequently diagnosed form of facial pain
• Nicolaus Andre (1756): “tic douloureux” = the facial spasms
accompany the attacks
• Also known as :
• Prosopalgia
• Fothergill's Disease
• Suicide Disease
Trigeminal Neuralgia (TN)
• prevalence of 4 per 100,000
• higher incidence in females
• peak incidence between 45 and 59 years
• Decreasing the quality of life of the patients
• Pokdi Nyeri Perdossi (2002) : di 14 rumah sakit pendidikan di seluruh
Indonesia
• 9,5% dari 4456 kasus nyeri merupakan kasus nyeri neuropatik yang
merupakan gabungan nyeri neuropati diabetika, nyeri paska herpes, dan
neuralgia trigeminal
Anatomy
 Aetiology of Trigeminal Neuralgia (TN)

Most of patients TN  no identifiable cause

Sabalys G; et al: Aetiology and Pathogenesis of Trigeminal Neuralgia: a Comprehensive Review, J Oral Maxillofac Res 2012 (Oct-Dec) | vol. 3 | No 4
Disease Characteristics
• Intermittent, stabbing pain in at least one trigeminal nerve dermatome
unilaterally
• rare cases  from bilateral trigeminal neuralgia
• The pain disease process normally affects the V2 and V3 distributions of
suffering patients
• autonomic symptoms occurred in 31% of patients with trigeminal neuralgia
on the same side as the pain
• conjunctival injection or tearing, miosis, ptosis, sweating, and clogged nose
that occurs unilaterally with the intermittent pain
• pain in the cheek, jaw, teeth, gums, and lips
• tingling or numbness in the face before starting to feel pain
NT triggered by :
• brushing teeth
• shaving
• rubbing
• touching the painful area of
the face
• putting on makeup
• eating or drinking
• speaking
• being exposed to the wind
Diagnosis
1. Clinical
2. based on the International Classification of Headache Disorders

Jones M; et al : A Comprehensive Review of Trigeminal Neuralgia, Current Pain and Headache Reports (2019) 23: 74C
Magnetic Resonance Imaging (MRI)
the most usefull imaging technique to determine the
presence of lesions :
• cysts or tumor
• vascular malformations
• plaque of multiple sclerosis
• vascular compression of the trigeminal nerve.
International Classification of Headache
Disorders edition 3 (ICHD-3) Diagnostic
Criteria for Trigeminal Neuralgia

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

Differential Diagnose

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020
International Dental Journal of Student Research; June 2016;4(2):79-82
Pharmacology Treatment

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

ELSEVEIR JOURNAL,WORLD NEUROSURGERY: X 6: 100070, APRIL 2020
Physical Medicine & Rehabilitation Programs
The goal of Rehabilitation Programs :
• Pain Relief
• Decrease pain frequency and severity of attack
• Eliminate perpetual fatique
• Lessen psychological distress
• Improve the ability to perform normal activities
• Improve quality of life
Consideration of Physical Medicine and Rehabilitation
Programs
• Effect of pharmaco therapy may be temporary and eliminate the
symptom only for a short periode.
• Surgery  have a lot side effect and the cost is not affordable to all
patients.
• Physical medicine and Rehabilitation program as non-invasive
treatment in relieving the burden of symptom TN
Physical Medicine and Rehabilitation Modalities :
1. Transcutaneus Electrical Nerve Stimulation (TENS)
• Reducing pain through:
• nociceptive inhibition in the presynaps level in the dorsal horn
• Endogenous pain inhibitory system (increasing endorphin and met-encephalin)
• Gate control theory  preventing the central transmission of the nociceptive
information to the cortex by stimulation of the large diameter afferent
• Application :
• Frequency 150 Hz
• Pulsed width 20 µs
• Intensitas executively set at subject sensory threshold
• Time 20 minute
• Self adhesive electrode pad site on the side of face of pain
2. Ultrasound Diathermy (USD)
• Non thermal effect US
• pulsed wave exposure  cavitation & acoustic streaming effect : anti
inflammatory & tissue stimulating effects
• Application :
• Pulsed ratio 50%
• Intensity 50 w/cm2
• Frequency 1 MHz
• Site : anterior to opening ear canal
3. Low Level LASER Therapy
• Anti inflamatory
• Increase cell proliferation & collagen production
• Reduces prostaglandin E2 (PGE2) & Cyclooxygenase-2 (COX-2) in cell level
• Application :
• Frequency 1500 Hz
• Dose 2 J/cm2/point
4. Superfisial moist heat (Hot Pack)  to reduce muscular tension in
cervical and Trapezius
5. Massage: Trapezius, Scalenus, SCM, Masseter, Temporalis Muscles,
pterygoid
• Relaxation reducing muscle tension to relief the pain

Zamani S, et al : Physiotherapy approachin Treatment NT , Journal of Clinical Physiotherapy Research, 2018

7. Exercises
• Releasing endorphin
• Reliave stress
• Improve mood and sleep
• Biofeedback training due to perpetual tension in facial muscles  make
patients aware of the abnormality activities of the facial muscles  to
eliminate abnormal behaviour patterns
• Stretching Exercises : Trapezius, Scalenus, SCM, flexor & extensor cervical muscles
• Strenghening Exercise : Isometric strengthening  progressed to the resistive exercise

Zamani S, et al : Physiotherapy approachin Treatment NT , Journal of Clinical Physiotherapy Research, 2018

PROGNOSIS

• TN is characterised by recurrences and remissions

• Many people have periods of remission with no pain lasting months
or years
• but in many, TN becomes more severe and less responsive to
treatment over time, despite increasing pharmacological intervention
THANK YOU