Trigeminal neuralgia

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TRIGEMINAL NEURALGIA

TRIGEMINAL NEURALGIA

TRIGEMINAL NEURALGIA Or TIC DOULOUREUX Or TRIFACIAL NEURALGIA Or FOTHERGILL’S NEURALGIA

  • Trigeminal neuralgia characterized by intermittent, shooting pain in the face.
  • Most debilitating form of neuralgia affecting the sensory branches of 5th C.N.
  • Disorder of peripheral or central fibres of Trigeminal nerve.
  • 95% of causes of trigeminal neuralgia are due to pressure on trigeminal nerve close to where it enters the brain stem, past the Gasserian ganglion. In most cases, this pressure seems to be caused by an artery or vein compressing trigeminal nerve.

DEFINITION:

  • It is defined as Sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve
  • Trigeminal neuralgia also known as Prosopalgia or Fothergill’s disease is a neuropathic disorder characterized by episodes of intense pain in the face, originating from trigeminal nerve.

ETIOLOGY:

  • Vascular compression
  • Usually idiopathic
  • Demylination of the nerve
  • Multiple sclerosis
  • Petrous ridge compression
  • Post – traumatic neuralgia
  • Intracranial tumors
  • Intracranial vascular abnormalities
  • Viral etiology 
TYPES:
 
  • TYPICAL TRIGEMINAL NEURALGIA
  • ATYPICAL TRIGEMINAL NEURALGIA
  • PRE- TRIGEMINAL NEURALGIA
  • MULTIPLE SCLEROSIS RELATED TRIGEMINAL NEURALGIA
  • SECONDARY OR TUMOR RELATED TRIGEMINAL NEURALGIA
  • TRIGEMINAL NEUROPATHY OR POST-TRAUMATIC TRIGEMINAL NEURALGIA
  • FAILED TRIGEMINAL NEURALGIA
CLINICAL SYMPTOMS:
 
  • INCIDENCE 8:100000
  • AGE-5th-6th decade of life
  • SEX-female> male
  • AFFLICTION FOR SIDE-  right> left
  • DIVISION OF TRIGEMINAL NERVE INVOLVEMENT-  V2>V3>V1
  • Manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting,  lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve
  • Pain is usually confined to one part of one division of trigeminal nerve
  • Pain rarely crosses the midline.
  • Attacks do not occur during sleep common during day time.
  • Pain is of short duration, but may recur with variable frequency.
  • In extreme cases, the patient will have a motionless face – the ‘frozen or mask like face’.
  • Common trigger zone include- cutaneous( corner of the lips, cheek, ala of the nose, lateral brow); intraoral( teeth, gingivae, tongue). Trigger area on the face are so sensitive that touching or even air currents can trigger an episode.
  • 10-12% of cases are bilateral, or occurring on both sides. This mainly seen in cases with systemic involvement include multiple sclerosis or expanding cranial tumor.
DIAGNOSIS
 
  • From a well taken history
  • CT- scan
  • MRI
  • Diagnostic nerve block
DIFFERENTIAL DIAGNOSIS:
 
  • MIGRAINE– severe type of periodic headache is persistent, at least over a period of hours and it has no trigger zone.
  • SINUSITIS– pain is not paroxysmal, in this pain is persistent, associated nasal symptoms.
  • DENTAL PAIN– localized, related to biting or hot or cold foods, visible abnormalities on oral examination.
  • Tumors of nasopharynx–  in this similar type of pain is produced, manifested in the lower jaw, tongue and side of the head with associated middle ear deafness. This complex lesion is called TROTTER’S syndrome. Patient exhibit asymmetry and defective mobility of the soft palate and affected side. As the tumor progresses, trismus of internal pterygoid muscle develops, and patient is unable to open the mouth. Here actual cause of pain is involvement of mandibular nerve in the foramen ovale.
  • Post herpetic neuralgia- pain is usually involved in ophthalmic division. The history of skin lesion prior to onset of neuralgia, pain is persistent, associated nasal symptoms.
TREATMENT:
 
MEDICAL
 
  • First line of treatment is CARBAMAZIPINE ( anticonvulsant)
  • Second line of treatment is: BACLOFEN, LAMOTRIGINE, OXCARBAZEPINE, PHENYTOIN, GABAPENTIN, PREGABALIN, SODIUM VALPROATE.
  • Low dose of Antidepressants such as AMITRYPTILINE are thought to be effective in treating neuropathic pain. Antidepressant are also used to counteract a medication side effect.
  • DULOXETINE  is helpful where neuropathic pain and depression are combined.
  • Opiates such as MORPHINE and OXYCODONE, there is evidence of their effectiveness on neuropathic pain, especially if combined with gabapentin, gallium maltoate in a cream or ointment base has been reported to relieve refractory postherpetic TN
SURGICAL
 
  • LONG ACTING ANESTHETIC AGENTS 
  • ALCOHOL INJECTION
  1. PERIPHERAL GLYCEROL INJECTION  
  2. PERIPHERAL NEURECTOMY( NERVE AVULSION)
  3. OPEN PROCEDURES ( INTRACRANIAL PROCEDURES)      
  • MICROVASCULAR DECOMPRESSION
  • PERCUTANEOUS RHIZOTOMIES
  • STEREOTACTIC RADIOSURGERY(Gamma Knife, Cyber Knife) 
Exam Question
 

TRIGEMINAL NEURALGIA Or TIC DOULOUREUX Or TRIFACIAL NEURALGIA Or FOTHERGILL’S NEURALGIA

  • Trigeminal neuralgia characterized by intermittent, shooting pain in the face.
  • Most debilitating form of neuralgia affecting the sensory branches of 5th C.N.
  • Disorder of peripheral or central fibres of Trigeminal nerve.
  • 95% of causes of trigeminal neuralgia are due to pressure on trigeminal nerve close to where it enters the brain stem, past the Gasserian ganglion. In most cases, this pressure seems to be caused by an artery or vein compressing trigeminal nerve.

DEFINITION:

  • It is defined as Sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve
  • Trigeminal neuralgia also known as Prosopalgia or Fothergill’s disease is a neuropathic disorder characterized by episodes of intense pain in the face, originating from trigeminal nerve.

ETIOLOGY:

  • Vascular compression
  • Usually idiopathic
  • Demylination of the nerve
  • Multiple sclerosis
  • Petrous ridge compression
  • Post – traumatic neuralgia
  • Intracranial tumors
  • Intracranial vascular abnormalities
  • Viral etiology
CLINICAL SYMPTOMS:
  • INCIDENCE 8:100000
  • AGE-5th-6th decade of life
  • SEX-female> male
  • AFFLICTION FOR SIDE-  right> left
  • DIVISION OF TRIGEMINAL NERVE INVOLVEMENT-  V2>V3>V1
  • Manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting,  lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve
  • Pain is usually confined to one part of one division of trigeminal nerve
  • Pain rarely crosses the midline.
  • Attacks do not occur during sleep common during day time.
  • Pain is of short duration, but may recur with variable frequency.
  • In extreme cases, the patient will have a motionless face – the ‘frozen or mask like face’.
  • Common trigger zone include- cutaneous( corner of the lips, cheek, ala of the nose, lateral brow); intraoral( teeth, gingivae, tongue). Trigger area on the face are so sensitive that touching or even air currents can trigger an episode.
  • 10-12% of cases are bilateral, or occurring on both sides. This mainly seen in cases with systemic involvement include multiple sclerosis or expanding cranial tumor.
DIAGNOSIS
  • From a well taken history
  • CT- scan
  • MRI
  • Diagnostic nerve block
DIFFERENTIAL DIAGNOSIS:
  • MIGRAINE- severe type of periodic headache is persistent, at least over a period of hours and it has no trigger zone.
  • SINUSITIS- pain is not paroxysmal, in this pain is persistent, associated nasal symptoms.
  • DENTAL PAIN- localized, related to biting or hot or cold foods, visible abnormalities on oral examination.
  • Tumors of nasopharynx-  in this similar type of pain is produced, manifested in the lower jaw, tongue and side of the head with associated middle ear deafness. This complex lesion is called TROTTER’S syndrome. Patient exhibit asymmetry and defective mobility of the soft palate and affected side. As the tumor progresses, trismus of internal pterygoid muscle develops, and patient is unable to open the mouth. Here actual cause of pain is involvement of mandibular nerve in the foramen ovale.
  • Post herpetic neuralgia- pain is usually involved in ophthalmic division. The history of skin lesion prior to onset of neuralgia, pain is persistent, associated nasal symptoms.
TREATMENT:
 
MEDICAL
  • First line of treatment is CARBAMAZIPINE ( anticonvulsant)
  • Second line of treatment is: BACLOFEN, LAMOTRIGINE, OXCARBAZEPINE, PHENYTOIN, GABAPENTIN, PREGABALIN, SODIUM VALPROATE.
  • Low dose of Antidepressants such as AMITRYPTILINE are thought to be effective in treating neuropathic pain. Antidepressant are also used to counteract a medication side effect.
  • DULOXETINE  is helpful where neuropathic pain and depression are combined.
  • Opiates such as MORPHINE and OXYCODONE, there is evidence of their effectiveness on neuropathic pain, especially if combined with gabapentin, gallium maltoate in a cream or ointment base has been reported to relieve refractory postherpetic TN
SURGICAL
  • LONG ACTING ANESTHETIC AGENTS 
  • ALCOHOL INJECTION
  1. PERIPHERAL GLYCEROL INJECTION 
  2. PERIPHERAL NEURECTOMY( NERVE AVULSION)
  3. OPEN PROCEDURES ( INTRACRANIAL PROCEDURES)      
  • MICROVASCULAR DECOMPRESSION
  • PERCUTANEOUS RHIZOTOMIES
  • STEREOTACTIC RADIOSURGERY(Gamma Knife, Cyber Knife) 
Don’t Forget to Solve all the previous Year Question asked on TRIGEMINAL NEURALGIA

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