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Trigeminal Neuralgia: Pedro Bernado
Trigeminal Neuralgia: Pedro Bernado
Neuralgia
Pedro Bernado
Trigeminal Neuralgia
predominance : 1.74 t0
1
Peak incidence 60-70
y.o.
Unusual before age 40
No racial predilection
Trigeminal Neuralgia
Higher incidence with multiple
BUT unusual
Most patients will have episodic
Classical Criteria
A. Paroxysmal attacks of pain lasting from a
factors
Classical Criteria
C. Attacks are stereotyped in
Symptomatic Criteria
A. Paroxysmal attacks of pain lasting from
factors
Symptomatic Criteria
C. Attacks are stereotyped
Pathophysiology
Pathophysiology
Trigeminal Neuralgia
Signs/Symptoms
Abrupt onset of excruciating pain
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
Red Flags
Hearing loss
Numbness
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
Smiling
Shaving
Applying make-up
Chewing
Wind
Teeth brushing
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
to carbamazepine, add or
substitute another
pharmacologic agent:
Medical Treatment
Medical Treatment
A recent Cochrane review said there was
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
AFP. 2008;77:1291-1296.
Cochrane Collaboration
Haanpaa M, et al. Neuropathic
Facial Pain. Suppl Clin
Neurophysiol. 2006;58:153-170.