Trigeminal neuralgia

1. NEURALGIAS
BY
S.MALLIKARJUN
BDS IV YR

2. NEURALGIA
Pain of severe throbbing or stabbing
character in the course of distribution of a
nerve.

3. TYPES OF NEURALGIAS
•TRIGEMINAL NEURALGIA
•PARATRIGEMINAL NEURALGIA
•SPHENOPALATINE NEURALGIA
•GLOSSOPHARYNGEAL NEURALGIA
•GENICULATE NEURALGIA
•OCCIPITAL NEURALGIA
•POST HERPETIC NEURALGIA

4. TRIGEMINAL NEURALGIA
Trigeminal neuralgia (TN) is sudden,
usually unilateral, severe, brief, stabbing,
recurrent episodes of pain in the
distribution of one or more branches of the
trigeminal nerve.

5. SYNONYMS
•Trifacial neuralgia
•Fothergill’s disease
•Tic-doloureux (painful jerking)

6. ETOIOLOGY
•INTRACRANIAL CAUSES
1.Petrous ridge compression-internal carotid artey
pulsations
2.Multiple sclerosis
3.Intracranial tumors- at the cerebellopontine angle
4.Intracranial vascular abnormalities-basilar artery
aneurysm, superior cerebellar artery abnormality

7. •EXTRACRANIAL CAUSES
1.Vascular factors
2.Dental etiology
3.Post traumatic neuralgia
4.Infections
5.Viral etiology

8. •Neuralgias and neuritis
•Syphilis
•Tuberculosis
•Tumor of the brain
•Basilar meningitis
•Pontine diseases .
•Skull fracture
•Aneurysm of the carotid
artery or circle of willis
•Psychoneuroses,and
•Cavernous sinus
thrombosis
Other disorders that may affect the trigeminal
nerve include :

9. PATHOPHYSIOLOGY
Atherosclerotic blood vessel pressing on the
root of Trigeminal nerve

Focal demyelination
Hyperexcitability of nerve fibres
Episodes of intense pain

12. TYPES OF TRIGEMINAL
NEURALGIA
•Pre Trigeminal neuralgia
•Idiopathic Trigeminal neuralgia
•Symptomatic neuralgia

13. •Pre trigeminal neuralgia: dull aching
pain usually observed before appearance
of trigeminal neuralgia
•Idopathic neuralgia: where the etiology
remains unknown
•Symptomatic neuralgia: the type in
which the etiology is known

14. CLINICAL FEATURES
•Incidence : 4 in 1,00,000
•Age : 4
th
to 5
th
decade
•Sex : F>M
•60% on the right side, 3%
bilateral.
•Mean age of onset-52-58yrs

15. Involvement : maxillary-60%
mandibular-49%
ophthalmic-16%
all 3 divisions-1%

16. •Manifests as sudden, unilateral,
intermittent, paroxysmal, sharp,
shooting, lancinating pain,
elicited by slight touch.
•Patient usually complains of
electric shock/lightening like
pain
•Usually confined to one part.
•Lasts for few seconds to
minutes.
•Motionless or mask like face.

17. •Rarely crosses the midline.
•Trigger points - Spontaneous attack or
triggered by trigger zone or movement of the
face as in chewing, talking, brushing or
yawning
•This leads patient frequently go unshaven or
unwashed
•Paroxysms occur in cycles.
•Depression and weight loss

18. Trigger zones are usually located on vermillion
border of lip, ala of the nose, cheek, chin, and
around the eye.

20. •There is generally no evidence of sensory
or motor impairment
•Apart from pain the other features are
itching & sensitivity of the face
•Rarely trigeminal neuralgia is associated
with hemi facial spasm- a condition called
TIC CONVULSIF that involves both V &
VII cranial nerves

21. DIAGNOSIS
•History
•Trigeminal nerve examination
•Diagnostic nerve blocking
•MRI (brain)
•EEG
•Microneurography

22. DIFFERENTIAL DIAGNOSIS
•Post herpetic neuralgia
•Dental pain
•Post traumatic neuralgia
•Multiple sclerosis
•Glossopharyngeal neuralgia
•Migraine
•SUNCT syndrome (sudden unilateral neuralgia type of
pain with conjunctival involvement)
•Migraine
•Tumors of nasopharynx( trotter`s syndrome)

23. MANAGEMENT
•PHARMACOLOGICAL
•SURGICAL
•OTHERS

24. PHARMACOLOGICAL
•FIRST LINE OF APPROACH
Carbamazepine 100, 200mg..
•SECOND LINE OF APPROACH
Phenytoin 100mg
Baclofen 5-80 mg/day
Lamotrigine 25 mg/day
•THIRD LINE OF APPROACH
Clonazepam 4-8 mg
Valproic acid 250-500 mg
Oxcarbazepine 1200mg/day

25. Other methods used are
•Trichloro ethylene inhalation
•Topical capsaicin cream application
•Proparacaine 0.5% anaesthetic drops in eye
•Anti inflammatory drug-Indomethacin & short
courses of steroids are found useful in some
cases

26. Review of Treatments – Medical
•Carbamazepine
(Tegretol)
•Gabapentin
(Neurontin)
•Baclofen
•Clonozepam
•Lamotrigin
•Oxcarbamazepine
•Phenytoin
•Amitriptyline
•Nortriptyline (Pamelor)
•Protriptyline
•Sumatriptan (cluster
headaches)
•NSAIDS / Opoids
•Capsaisin (topical)

27. SURGICAL
•Stereo tactically controlled thermo coagulation of
V cranial nerve
•Vascular decompression( through posterior
fossa craniotomy)
•Repositioning of the basilar artery( compressing
the V nerve)
•Micro vascular decompression
•Gamma knife radio surgery
•Cryotherapy

28. •Injection of the nerve with alcohol
•Local anaesthetic injection of the nerve
•Nerve sectioning & avulsion
•Percutaneous radiofrequency trigeminal
neurolysis
•Bulbar trigeminal tractotomy
•Glycerol rhizotomy

29. MICRO VASCULAR DECOMPRESSION

30. VASCULAR DECOMPRESSION

31. Review of Treatments –
Surgical
•MVD
•Radio Frequency
Rhizotomy
•Balloon Compression
•Glycerol Rhizotomy
•Gamma Knife
Radiosurgery
•Nerve Blocks
•Neurotomy
•NICO Surgery
•DREZ (Dorsal Root Entry
Zone)

32. OTHERS
•TENS – Transcutaneous Electric Nerve
Stimulation
•Acupuncher
•Psychological approach

33. Review of Treatments - Alternative
•Acupuncture
•Ayurvedic Medicine
•Botulinum Toxin (Botox)
•Cervical Chiropractic
•Exercise / Running
•Homeopathy
•Hot / Cold Compresses
•Hypnosis
•Low Intensity Laser
•Lidocaine Cream / Patch
•Myotherapy
•Osteopathy
•TENS (Postherpetic N.)
•Vitamin B12
•Yoga / Biofeedback

34. PARATRIGEMINAL NEURALGIA
•Also called as raeder’s syndrome
•Characaterised by severe headache or pain
in the distribution of trigeminal nerve with
signs of ocular sympathetic paralysis
•Homolateral pain in the head or eye
•Sudden appearance of signs and symptoms

35. •Most common in males
•Generally occurs in middle aged people
•It can be differentiated from horners
syndrome by presence of pain and no
change in sweating activity

36. SPHENOPALATINE NEURALGIA
•Also called as vidian nerve neuralgia or
hortons’s syndrome
•An idiopathic sydrome consisiting of
recurrent brief attack of sudden severe
unilateral periorbital pain.
•Typical periodicity has been attributed to
hypothalamic harmonal influences

37. •Pain is thought to be generated at the level
of pericarotid/ cavernous sinus complex
•Characterized by unilateral paroxysms of
intense pain in the region of the eyes,
maxilla, ear , mastoid, base of the nose, and
beneath the zygoma.
•Sometimes the pain extends intothe occipital
area as well.

38. •The paroxysms of pain hava a rapid onset,
persist for about 15 min, and to several
hours, and then disappears asrapidly as
they begin
•There is no trigger zone
•The attacks develop regularly, usually
atleast once a aday, over a prolonged
period of time

39. •The onset of paroxysm occur exactly in
the same time of the day, and for this
reason, the disease is referred to as
“alarm clock headache”
•Aftersome weaks or months, the trauma
disappears completely and this period of
freedom and may persist for month or
even for years

40. •Sneezing , swelling of nasal mucosa and
severe nasal discharge often appears
simultaneously with the painful attacks as
epiphohra or wattereing of eyes and blood
shoot eyes
•Paraesthestic senstation over the skin of
lower half of the face also are reported
•Men are more effected more commonly than
women (5:1)

41. •Treatment:
•Cocainization of sphenopalatine ganglion
or alcohol injection of this structure
•Resection of ganglion
•Surgical corrections of septal defects

42. GLOSSOPHARYNGEAL NEURALGIA
•It is a pain similar to trigeminal neuralgia
•Not as common as trigeminal neuralgia, but
when it occurs, the pain may be as severe
•The pain is sharp, shooting pain in the ear,
commonly in the nasopharynx, tonsils, posterior
portion of the tongue
•Etiology is unknown

43. •It occurs at any age period without age
predilection
•Numerous mild attacks may be
interspreaded by occassional severe one
•The patient usually has trigger zone in the
posterior oropharynx or tonsillar fossa

44. •Treatment:
•Resection of extra carnial portion of nerve
or intra cranial portion
•Injection of alcohol is not widely accepted

45. GENICULATE NEURALGIA
•Also called as nervous intermedius neuralgia
•It is uncommon paroxysmal neuralgia of
cranial nerve VII
•Characeterized by the pain in ear, anterior
part of tongue and soft palate
•This type of pain has a trigger zone

46. •The location of pain runs alsong the distribution
of neve(external auditory canal, small area of
soft palate, posterior auricular region)
•The pain is not as sharp and intense as
trigeminal neuralgia and often sometimes facial
paralysis, indicating the involvement of motor
root

47. •This pain results commonly from herpes zoster
of geniculate ganglion and nervus intermedius
of cranial nerve vii
•This condition is also referred to as ramsay
hunt syndrome
•Virus vesicles may be observed in the ear
canal or tympanic membrane
•Acyclovir significantly reduces the duration of
pain

48. •Symptoms result from nflammatory neural
degeneration and short course(2 to 3
weks) of high steroid therapy
•Patient may also be treated with
carbamazepine and antidepressants
•Patient may also undergo surgery of
nervous intermidius if he doesn’t respond
to the above medication

49. OCCIPITAL NEURALGIA
•Rare neuralgia in the distribution of the
sensory branches of cervical plexus
•The most common cause are trauma,
neoplasms, infections and aneurysms of
effected nerves
•Palpation below the superior nuchal line
may reveal an exquisitely tender spot

50. •Treatment has included corticosteroids,
neurolysis, avulsion and blocking the
nerve with local anesthetic solution

51. POST HERPETIC NEURALGIA
It is caused by reactivation of varicella-
zoster virus infection
15-20% of cases of herpes zoster invoule
trigeminal nerve
Majority cases affect ofhthalamic division of
5
th
nerve

52. Characterized by pain and lesions in the
region of eyes and forehead
Infection of maxiilary and mandibilar
divisions cause facial and oral pain
Pain resolves within month after the lesions
heal
Mostly affects elderly people.

53. Pathogenesis
•The vz virus injures the periphral nerve by
demyelination, wallerian degeneration and
sclerosis
•Atrophy of dorsal horn cells in the spinal
cord
•Patient exhibits painfull response to non
painfull stimuli

54. Clinical features
•Pain paresthesia. Hyperesthasia and
alodynia persists months to years after
zoster lesions have healed
•Pain is accompanied by a sensory deficit
in the region of nerve distrubtion

55. TREATMENT
•Topical therapy: lidocaine,
capsaicin,EMLA cream.
•Tricyclic antidepressants: amitriptyline,
nor triptyline, doxepin, desiprimine
•Others: gabapentin, carbamazepine,
phenytoin

56. •Surgery: nerve blocks peripheral nerve
sresection, dorsal root surgery
•Prevention:antiviral drug (famciclovir) and
corticosteroids

57. THANK YOU