Trigeminal Neuralgia

Anwar Wardy W
Dept. Neurology FK UMJ

fk umj. dept.neurosains 2011

anwar wardy w

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

fk umj. dept.neurosains 2011

anwar wardy w

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

fk umj. dept.neurosains 2011

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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
fk umj. dept.neurosains 2011

anwar wardy w

fk umj. dept.neurosains 2011

anwar wardy w

fk umj. dept.neurosains 2011

anwar wardy w

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.

fk umj. dept.neurosains 2011

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Pathophysiology

fk umj. dept.neurosains 2011

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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
fk umj. dept.neurosains 2011

anwar wardy w

Trigeminal Neuralgia
Diagnostic Criteria:
A. Paroxysmal attacks of facial pain lasting a few seconds
to < 2 minutes
B. Pain with at least 4 of the FF criteria:
1. Pain confined to one or more divisions of the nerve
2. Pain that is sudden, intense, sharp, superficial,
stabbing or burning in quality
3. Pain with severe intensity
4. Pain precipitated by stimulation of trigger areas

Trigeminal Neuralgia
Diagnostic Criteria:
C. No neurologic deficit
D. Attacks that are stereotyped in the individual
E. Other causes of facial pain are excluded

Trigeminal Neuralgia
Pathogenesis:

Focal demyelination of the main sensory root by

compression with a loop of artery or vein

Permits ephaptic impulse formation

Degenerative changes in the gasserian ganglion
Trigger zones are present in 90% of cases
Tic douloureux

Trigeminal Neuralgia
Medical Management:
1. Baclofen (Lioresal)- 5 mg TID
2. Carbamazepine (Tegretol) - 50-100mg TID; pain
relief in 70% patients
3. Sodium valproate 4. Clonazepam 3-8 mg/ day

Trigeminal Neuralgia
Surgical Management:
1. Microvascular decompression (Janetta
procedure): 80% long-term relief
2. Radiofrequency thermocoagulation of the
Gasserian ganglion
3. Peripheral branch alcohol injection (gangliolysis)
risks: anesthesia dolorosa

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

fk umj. dept.neurosains 2011

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Red/White? Flags
Abnormal Neuro exam

Abnormal oral, dental, or ear exam

Age < 40 yrs

Bilateral SXs

Dizziness or vertigo

fk umj. dept.neurosains 2011

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Red Flags
Hearing loss

Numbness

Pain lasting > 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
Sharp
Superficial
fk umj. dept.neurosains 2011

Stereotypical
Stabbing
Shock-like
anwar wardy w

Diagnostic History
1 or more of the nerves divisions
Trigger factors:
Talking
Smiling
Chewing
Teeth brushing

Shaving
Applying make-up
Wind

Age > 40 yrs.

Ask about other neuro Sx
Asymptomatic time or not ?
fk umj. dept.neurosains 2011

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Physical Exam
Usually a normal exam
Useful for identifying abnormals that point to
other DXs

HEENT, including Masseter

Oral exam, including teeth & gums
Neuro exam
Check for trigger zones

fk umj. dept.neurosains 2011

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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

fk umj. dept.neurosains 2011

anwar wardy w

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

fk umj. dept.neurosains 2011

anwar wardy w

Treatment
Medical
Surgical
No Behavioral, unless it becomes a
cause of Chronic Pain
fk umj. dept.neurosains 2011

anwar wardy w

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.)
fk umj. dept.neurosains 2011

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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:

fk umj. dept.neurosains 2011

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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 nonepileptic agents in trigeminal
neuralgia

fk umj. dept.neurosains 2011

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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)

fk umj. dept.neurosains 2011

anwar wardy w

Surgical Treatment
After failure of Pharm agents
Unusual
Recurrences occur for many
Both percutaneous & open techniques
Glycerol injection
Radio Rhizotomy
Partial Rhizotomy

fk umj. dept.neurosains 2011

Ballon Compression
Gamma knife
Microvascular
decompression

anwar wardy w

Summary
2 Types of trigeminal neuralgia
A clinical DX
Everyone gets a head & face
MRI

Carbamazepine is the
treatment of choice.
fk umj. dept.neurosains 2011

anwar wardy w

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.
fk umj. dept.neurosains 2011

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References
Cruccu G, et al. Diagnosis of trigeminal
neuralgia. In: Cruccu G, et al. Brainstem
Function & Dysfunction. Amsterdam: Elsevier;
2006:171-186.

Wassalam,..Terima kasih
Jakarta, 2011, April
Anwar Wardy W

fk umj. dept.neurosains 2011

anwar wardy w