Professional Documents
Culture Documents
Trigeminal Neuralgia: Anwar Wardy W Dept. Neurology FK UMJ
Trigeminal Neuralgia: Anwar Wardy W Dept. Neurology FK UMJ
Anwar Wardy W
Dept. Neurology FK UMJ
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
fk umj. dept.neurosains 2011
anwar wardy w
Tic Doloureau
Higher incidence with M.S. & HTN
Spontaneous remission possible,
BUT unusual
anwar wardy w
anwar wardy w
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.
anwar wardy w
Classical Criteria
C. Attacks are stereotyped in
the individual patient
anwar wardy w
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.
anwar wardy w
anwar wardy w
anwar wardy w
Symptomatic Criteria
C. Attacks are stereotyped
in the individual patient
anwar wardy w
Pathophysiology
anwar wardy w
? Pathophysiology ?
Demyelination of the trigeminal nerve, causing
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:
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
anwar wardy w
Red/White? Flags
Abnormal Neuro exam
Bilateral SXs
Dizziness or vertigo
anwar wardy w
Red Flags
Hearing loss
Numbness
Visual changes
anwar wardy w
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
anwar wardy w
Physical Exam
Usually a normal exam
Useful for identifying abnormals that point to
other DXs
anwar wardy w
Diagnostic Testing
Generally Not helpful
MRI is the Test of Choice : C Rec
? Trigeminal reflex testing? Unclear usefulness
& I would NOT do it
anwar wardy w
Differential List
Cluster HA
Dental Pain
Migraine
Glossopharyngeal
Neuralgia
Otitis Media
Intracranial Tumor
Sinusitis
Multiple Sclerosis
TMJ Syndrome
Postherpetic Neuralgia
Paroxysmal
Hemicrania
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
anwar wardy w
Medical Treatment
Carbamazepine Should be the initial Rx of
choice for classical Trigeminal Neuralgia
anwar wardy w
Medical Treatment
Other agents to try : ( Not listed in any order)
Baclofen : 10 m- 80 mg daily
Dilantin
Lamictal
Neurontin
Topamax
Klonopin
Orap
Depakene
fk umj. dept.neurosains 2011
anwar wardy w
Medical Treatment
A recent Cochrane review said
there was insufficient evidence
to show benefit from nonepileptic agents in trigeminal
neuralgia
anwar wardy w
Follow-up
Achieve balance between pain and med side
effects
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
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
anwar wardy w
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
anwar wardy w