Pedro Bernado

Trigeminal Neuralgia
4.3 per 100,000
Slight female
predominance : 1.74 t0 1
Peak incidence 60-70 y.o.
Unusual before age 40
No racial predilection
 Trigeminal Neuralgia
Higher incidence with multiple sclerosis
and hypertension

Spontaneous remission possible, BUT

unusual

Most patients will have episodic attacks

over many years
 Now 2 Types Are Identified
Classical

Symptomatic
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
Classical Criteria
C. Attacks are stereotyped in
the individual patient

D. No clinically evident neuro deficit

E. Not attributed to another disorder.

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
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.
Pathophysiology
 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
A-V malformation
Pons Infarct
Bony compression
 Trigeminal Neuralgia
Signs/Symptoms
Abrupt onset of excruciating pain
-ophthalmic, maxillary, mandibular branches
Trigger zone/specific point stimulation along nerve
branches
-chewing,tooth-brushing,washing face, yawning,
talking, applying makeup, blast of cold or hot air in
face
Most common trigger is touch or tickle on face
Pain: burning/knife-like/ lightning shock in upper
and/or lower gum/cheeks, forehead, side of nose, lips
 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
 Red Flags
Abnormal Neuro exam

Abnormal oral, dental, or ear exam

Age < 40 yrs

Bilateral

Dizziness or vertigo
 Red Flags
Hearing loss

Numbness

Pain lasting > 2 minutes

Pain outside of trigeminal distribution

Visual changes
 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
 Diagnostic History
1 or more of the nerves divisions
Trigger factors:
Talking Shaving
Smiling Applying make-up
Chewing Wind
Teeth brushing
Age > 40 yrs.
Ask about other neuro Sx
Asymptomatic time or not ?
 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
 Diagnostic Testing
Generally Not helpful
MRI is the Test of Choice : C Rec
Trigeminal reflex testing? Unclear usefulness
Differential List
Cluster HA Dental Pain
Giant Cell Arteritis Migraine
Neuralgia Otitis Media
Intracranial Tumor Sinusitis
Multiple Sclerosis TMJ Syndrome
Postherpetic Neuralgia
Glossopharyngeal
 Treatment
Medical

Surgical

No Behavioral, unless it becomes a cause of Chronic

Pain
 Medical Treatment
Carbamazepine : A Rec
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
 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:
Medical Treatment
 Medical Treatment
A recent Cochrane review said there was insufficient
evidence to show benefit from non-epileptic agents in
trigeminal neuralgia
 Follow-up
Achieve balance between pain and med side effects
Most want complete remission, which is possible and
warranted
 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
 Summary
Two types of trigeminal neuralgia
A clinical Diagnosis
Everyone gets a head & face MRI
Carbamazepine is the treatment of
choice.
 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.