B.

Wayne Blount, MD, MPH

 “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
 “Tic Doloureau”

 Higher incidence with M.S. & HTN

 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
 Amyloid
 A-V malformation
 Pons Infarct
 Bony compression
 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 SXs

 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 100’s of times per day
 Pain :
 Severe Stereotypical
 Sharp Stabbing
 Superficial Shock-like
 Diagnostic History

 1 or more of the nerve’s 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 & I would NOT do it
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
 Treatment

 Medical

 Surgical

 No Behavioral, unless it becomes a cause of

Chronic Pain
 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.)
 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

 Other agents to try : ( Not listed in any order)

 Baclofen : 10 m- 80 mg daily
 Dilantin
 Lamictal
 Neurontin
 Topamax
 Klonopin
 Orap
 Depakene
 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
 Can try a trial sans meds after “several”
months symptom free (Think 4-6)
 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

 2 Types of trigeminal neuralgia

 A clinical DX
 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.
 References

 Cruccu G, et al. Diagnosis of trigeminal

neuralgia. In: Cruccu G, et al. Brainstem
Function & Dysfunction. Amsterdam:
Elsevier; 2006:171-186.
 Wayne Blount