Trigeminal neuralgia - made easy

1. TRIGEMINAL NEURALGIA DR. ANGELO SMITH M.D WELLING HEALTHCARE PRIVATE LTD

2. Trigeminal neuralgia

3. INCIDENCE Also called tic douloureax Uncommon cranial nerve disorder More common in women @ 50-60 years of age – 3:2 ratio. Trigeminal nerve is 5 th cranial nerve (CNV) And has both motor and sensory branches; mostly maxillary and mandibular branches involved.

4. Trigeminal neuralgia

5. Causal Factors Initiating pathologic events include: nerve compression by tortuous arteries of the posterior fossa blood vessels demyelinating plaques herpes virus infection infection of teeth and jaw a brainstem infarct

6. Pathophysiology Classical (idiopathic) form There is no known cause for the, however, studies point to an underlying vascular pathology as a cause by irritation over the trigeminal (Gasserian) ganglion. Age of onset – 52 – 58 yrs Symptomatic (secondary) form, There are known common causes affecting the CNV Compression of the trigeminal ganglion Demyelinating Disorder (axonal hyper excitability) Age of onset – 30 – 35 yrs

7. Compression of the Trigeminal Ganglion Vascular Tortous atherosclerotic branch of the basilar artery Basilar artery aneurysm Cerebello -Pontine Angle (CPA) Mass Meningioma Chordoma Neurinoma Metastatic (nasopharyngeal Ca)

8. Demyelinating Disorder #2 (axonal hyperexcitability ) Multiple sclerosis (MS) – plaques at the nerve root entry After nerve injury Post-trauma Post-dental procedure Post- mandibular trauma

9. Demyelinating Disorder #3 (axonal hyperexcitability) Post-infectious Herpes zoster Tympanomastoiditis Dental carries ( micro abscesses and pulp degeneration) Inflammatory Connective tissue disease ( Sjogren’s Disease)

10. Clinical manifestations Abrupt onset with excruciating pain!! Pain described as burning, knifelike, or lighting like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose. Patient may twitch, grimace, frequent blinking and tearing of eye (tic) may occur. Affects the face near the nose or mouth (trigger points) Graded using the Visual Analog Scale (VAS) of 0/10 without pain to 10/10 with severe pain

11. Clinical manifestations Attacks may be brief (2 or 3 minutes) Unilateral Episodes may be initiated by triggering mechanism of light cutaneous stimulation as a specific point (trigger zone) along nerve branches. With no demonstrable sensory nor motor deficits Attacks may be restricted to 1 or 2 divisions of the trigeminal nerve Usually involves the 2 nd branch (maxillary) and/or 3 rd branch (mandibular) division.

12. Precipitating stimuli Chewing, brushing teeth, hot or cold blast of air on the face, washing the face, yawning, or talking. Patient may eat improperly, neglect hygiene practices, wear cloth over face, withdraw from interaction with others.

13. Differential Diagnosis: Demyelinating (MS)  Neurology CPA tumors  Neurosurgery Nasopharyngeal and Para nasal pathology  ENT Dental Pathology  Dentistry Herpes zoster  Neurology Classical  Medications  Neurosurgery Unstable angina  Cardiology

14. Diagnostic studies Need to rule out other neurological causes of facial and cephalic pain. CT scan will rule out brain lesions, vascular malformations. LP and MRI will r/o MS. There is no specific diagnostic test for TN.

15. General Algorithm FACIAL PAIN History Physical Examination (PE) Neurological Examination (NE) Diagnostic Options: Brain MRI/MRA Brain CT/CTA Audiometry Evoked potentials Cardiac work-up Clinical Symptomati c Referred

16. Therapeutic Options Pharmacologic Antiepileptic drugs Anticonvulsant drugs have been used in the management of pain since the 1960s and the clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning. Non-antiepileptic drugs Surgical

17. Antiepileptic Drugs (AED) Carbamazepine Phenytoin Gabapentin Pregabalin Clonazepam Sodium Valproate / Divalproex Lamotrigine Oxcarbazepine

18. TN Pain Carbamazepine + Baclofen Carbamazepine Pregabalin Carbamazepine + Gabapentin Phenytoin Phenytoin + Baclofen Clonazepam Sodium Valproate Lamotrigine Oxcarbazepine Surgical Treatment AED +/- Painless for 6 weeks Taper dose in 4 weeks With recurrence

19. Non-Antiepileptic Drugs Baclofen Tocainide Pimozide Chloripramine Amitriptyline Tizanidine Proparacaine

20. Non-pharmacologic: Surgical Peripheral Neurectomy supraorbital, infraorbital and mental nerves Intracranial trigeminal rhizotomy portio major Glycerol gasserian gangliolysis Microvascular decompression Stereotactic radiosurgery Radiofrequency rhizotomy

21. Recurrence of Trigeminal Neuralgia Recurrence of Trigeminal Neuralgia Medical Treatment Surgical Treatment