trigeminal neuralgia (tic douloureux)
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Etiology
- compression of the trigeminal nerve
- between the gasserian ganglion & the pons
- vascular loop at the level of the root entry to the pons
- usually the superior cerebellar artery
- benign tumors
- nasopharyngeal carcinoma
- multiple sclerosis
Epidemiology
- generally > 50 years of age
- women affected more than men
Clinical manifestations
- paroxysmal pain in the distribution of the trigeminal nerve
- quality: intense, stabbing, lacinating
- duration: a few seconds to 2 minutes
- frequency: 1-2 attacks/day to 10-20 attacks/hour
- diurnal variation: fewer episodes at night
- generally unilateral pain
- usually involves 2nd & 3rd divisions of the trigeminal nerve
- rarely involves the ophthalmic division
- pain may be spontaneous or triggered by sensory stimuli of the face or mouth
- 24-49% of patients report continuous or long-lasting pain, burning, throbbing, or aching between paroxysmal pain[7]
- examination of sensory & motor components of cranial nerve 5 is often normal
- associated cranial nerve abnormalities suggest mass lesion
Radiology
- contrast-enhanced magnetic resonance imaging (all patients)[6]
- non-vascular structural pathology (15%)
- superior cerebellar artery involved in vascular compromise or structural compression of trigeminal nerve (85%)
Differential diagnosis
- multiple sclerosis
- postherpetic neuralgia
- glossopharyngeal neuralgia
- Raeder's paratrigeminal syndrome
- atypical facial neuralgia
- chronic cluster headache syndrome (Horton's cephalgia)
- cluster headaches
- post-traumatic facial neuralgia
- temporomandibular joint (TMJ) syndrome
- dental pain
- sinus pain
Management
- pharmacologic agents
- carbamazepine (Tegretol) is treatment of choice[2]
- begin 200 mg/day
- increase 100-200 mg every 2-3 days to a max of 1200 mg/day
- divide larger doses TID
- routine laboratory tests (periodic)
- 80% of patients obtain pain relief
- oxacarbazine is alternative to carbamazepine
- lamotrigine, gabapentin, botulinum toxin type A, pregabalin, baclofen, & phenytoin may be used either alone or as add-on therapy[6]
- intravenous fosphenytoin or lidocaine for acute pain[6]
- carbamazepine (Tegretol) is treatment of choice[2]
- surgery reserved for patients refractory to medical therapy
- at least 3 drugs or drug combinations should be tried before surgery is considered[2]
- gamma knife radiosurgery[2][3]
- percutaneous trigeminal neurolysis
- placement of a needle or electrode through the foramen ovale to the trigeminal cistern of Meckel's cave
- destruction of the gasserian ganglion & retrogasserian rootlets
- glycerol injection
- radiofrequency thermocoagulation (rhizotomy)
- no general anesthesia
- microvascular decompression
- general anesthesia
- retromastoid craniectomy
- removes offending vascular structure from nerve
- spares trigeminal nerve
More general terms
Additional terms
- trigeminal (semilunar) ganglion; gasserian ganglion
- trigeminal autonomic cephalgia
- trigeminal nerve (CN V)
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1043-45
- ↑ 2.0 2.1 2.2 2.3 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19 American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
- ↑ 3.0 3.1 Chole R, Patil R, Degwekar SS, Bhowate RR. Drug treatment of trigeminal neuralgia: a systematic review of the literature. J Oral Maxillofac Surg. 2007 Jan;65(1):40-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17174762
- ↑ Bigal ME Diagnostic evaluation and treatment of trigeminal neuralgia. Curr Pain Headache Rep. 2009 Aug;13(4):256-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19586587
- ↑ Maarbjerg S, Gozalov A, Olesen J, Bendtsen L. Trigeminal neuralgia--a prospective systematic study of clinical characteristics in 158 patients. Headache. 2014 Nov-Dec;54(10):1574-82. Epub 2014 Sep 18. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25231219
- ↑ 6.0 6.1 6.2 6.3 6.4 European Academy of Neurology Trigeminal Neuralgia Clinical Practice Guidelines (2019) Medscape - Aug 01, 2019. https://reference.medscape.com/viewarticle/916210
- ↑ 7.0 7.1 Rothaus C Trigeminal Neuralgia NEJM Resident 360. August 19, 2020 https://resident360.nejm.org/clinical-pearls/trigeminal-neuralgia
- ↑ Gronseth G, Cruccu G, Alksne J et al Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct 7;71(15):1183-90. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18716236 Review.
- ↑ Krafft RM. Trigeminal neuralgia. Am Fam Physician. 2008 May 1;77(9):1291-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18540495 Free article. Review.
- ↑ Oomens MA, Forouzanfar T. Pharmaceutical Management of Trigeminal Neuralgia in the Elderly. Drugs Aging. 2015 Sep;32(9):717-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26336972 PMCID: PMC4579266 Free PMC article. Review.
- ↑ NINDS Trigeminal Neuralgia Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Trigeminal-Neuralgia-Information-Page