Trigeminal neuralgia

CONTENTS
 Introduction
 Definition
 Classification
 Etiology and Pathogenesis
 Clinical features
 Diagnosis
 Treatment and management
 References
 INTRODUCTION
Anatomy of Trigeminal nerve
 trigeminal nerve
 The trigeminal nerve (the fifth cranial nerve, or simply CN
V) is a nerve responsible for sensation in the face and motor
functions such as biting and chewing; it is the largest of the
cranial nerves.
 three large branches. They are :
 ophthalmic (V1, sensory), maxillary (V2, sensory) and
mandibular (V3, motor and sensory) branches. The large
sensory root and smaller motor root leave the brainstem at
the midlateral surface of pons.
 DEFINITION

• Sudden,usually nilateral,
severe brief stabbing pain
in the distribution of one
of more branches of the
V nerve.
 Cont.
 Trigeminal neuralgia is sudden, severe facial pain. It's often
described as a sharp shooting pain or like having an electric
shock in the jaw, teeth or gums.
 It usually occurs in short, unpredictable attacks that can last from
a few seconds to about two minutes. The attacks stop as suddenly
as they start. 
 In most cases trigeminal neuralgia affects part or all of one side
of the face, with the pain usually felt in the lower part of the face.
 Very occasionally it can affect both sides of the face, although
not usually at the same time.
 CLASSIFICATION:

International Headache Society (IHS) classified

trigeminal neuralgia into two types:
 Classical /idiopathic/typical
 Symptomatic
 Classical trigeminal neuralgia
is a unilateral disorder
characterized by brief
electric, shock- like pains.
They are abrupt in
termination limited to the
distribution of one or more
divisions of trigeminal nerve
 Symptomatic trigeminal
neuralgia
Pain is similar to classical type
But it is it caused by demonstrable
structural lession other then vascular
compression.
 Ethology of trigeminal neuralgia

INTRACRANIAL CAUSES
1. Petrous ridge compression-internal carotid artery
pulsations.
2. Multiple sclerosis
3. Intracranial tumors-at the cerebellopontine angle
4. Intracranial vascular abnormalities- basilar artery
aneurysm, superior cerebellar artery abnormality
 Extracranial causes
Vascular factors
Dental etiology
Post traumatic neuralgia
Infections
Viral etiology
 other disorders that may affect the
trigeminal nerve include :

 Syphilis
 Tuberculosis
 Skull fracture
 Aneurysm of the carotid artery or circle of willis
 Tumor of the brain
 Basilar meningitis
 CLINICAL FEATURES
Rare
Middle age
Female predilection (60%)
Maxillary division more commonly involved
Opthalmic division rarely involved
Shaving, showering, speaking, eating, or
exposure to wind triggers episodes
Contd…….
CLINICAL FEATURES……………….

Pain occurs in areas of the face where the

trigeminal nerve supplies normal sensation:
cheek, jaw, teeth, gums and lips, and
sometimes the eye or forehead
The pain is described as episodes of intense
feeling like stabbing, electric shocks, burning,
burning, crushing, exploding lanceration pain
Pain lasts few second to minutes
Trigger zones
DIAGNOSIS

 History
 Clinical examination
 Diagnostic LA blocks
 CT scan
 MRI
Pain History

 Chief complaint
 History of present illness
 Current symptoms:Onset, Location,
Quality, Intensity, Frequency, Duration
 Aggravating and alleviating factors
 Past treatments
diagnostic criteria for trigeminal
neuralgia
Classic trigeminal neuralgia
A. Paroxysmal attacks of facial or frontal pain
that last a few seconds to less than 2 minutes,
affecting one or more divisions of the
trigeminal nerve and fulfilling criteria B and
C.
B. Pain has at last one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2.Precipitated from trigger areas or by trigger
factors.
3.The patient is entirely asymptomatic between
paroxysms.
C. Attacks are stereotyped in the
individual
patient no clinically evident
. neurological
D.There
E. Not attributed to another
is
disorder.
deficit.
Symptomatic trigeminal neuralgia
A. Paroxysmal attacks of pain lasting from a
fraction of a second to 2 minutes, with or
without persistence of aching between
paroxysms, affecting one or more divisions of
the trigeminal nerve and fulfilling criteria B.
 B. Pain has at least one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2.Precipitated from trigger areas or by trigger
factors
3.Attacks are stereotyped in the individual
patient
4. A causative lesion, other than vascular
compression, has been demonstrated by special
investigations and/or posterior fossa exploration.
Differential Diagnosis Of Classic
Trigeminal Neuralgia

1. Secondary trigeminal neuralgia

2. Pain of dental origin
3. Extracranial
4. Neuropathic
5. Neurovascular
6. Psychogenic
 Cont.
 Post herpetic neuralgia
 Dental pain Post traumatic neuralgia
 Multiple sclerosis
 Glossopharyngeal neuralgia
 Migraine
TREATMENT

Medical management

Surgical
management
 Medical management

CARBAMAZEPINE
 100 – 200mg, bd or tid
 Which provides benefit to more than
75% of patients
 Common trade names: Tegretol, Tegretol XL,
Carbitrol
 Mode of action
 Side effects
FIRST LINE OF APPROACH
Carbamazepine 100, 200mg.
SECOND LINE OF APPROACH
Phenytoin 100mg
Baclofen 5-80 mg/day
Lamotrigine 25 mg/day
 THIRD LINE OF APPROACH
Clonazepam 4-8 mg
 Valproic acid 250-500 mg
 Oxcarbazepine 1200mg/day
 SURGICAL
Removal of compression type.
Tumor removal
 microvascular decompression (MVD),
 Gamma Knife
 radiosurgery,
percutaneous rhizotomy and pain stimulator
placement.
 Surgical management
Surgical options have been reserved for those
patients
who have a clearly defined secondary cause
for the trigeminal neuralgia,
 who are unresponsive,
 who have severe, unremitting pain that
limits their ability to eat,
 for whom multiple medications are
intolerable or contraindicated
 Surgical options

Percutaneous glycerol rhizolysis

Percutaneous balloon compression
Radiofrequency trigeminal (retrogasserian)
rhizotomy
Gamma knife radiosurgery
Microvascular decompression
 REFERENCES:

Fonseca, Marciani, Turvey, Oral and

Maxillofacial surgery, 2nd edition, volumeII
,Saunders Elsevier, 2009.
Jafferey P. Okeson, Bells Orofacial pain, 6th
edition, Quintessence publishing co Inc,
2005.
Peterson, Ellis, Hupp, Tucker, Oral and
maxillofacial surgery, 4th edition, Elsevier,
2003.
 G.C. Manzoni , P. Torelli, Epidemiology of typical
and atypical craniofacial neuralgias, Neurol Sci
(2005) 26: S65–S67
 Abhishek singh nayyar, Mubeen Khan, Trigeminal
Neuralgia: Revisiting clinical characteristics in the
Indian scenario. A Journal of Medical science and
Technology. Volume I, Issue 2, August 2012; pages
9-17
 Cheryl A. Kitt et al., Topical review Trigeminal
neuralgia: opportunities for research and
treatment, International Association for the Study
of Pain, 2000.
END