27 - Trigeminal neuralgia and trigeminal autonomic cephalalgias Flashcards
What is neuralgia?
- intense stabbing pain, brief but severe
- pain will extend along course of nerve, which is irritated or damaged
Which cranial nerves can be affected by neuralgia?
- trigeminal
- glossopharyngeal and vagus
- nervus intermedius (facial nerve)
- occipital
Who is typically affected by trigeminal neuralgia?
- F>M
- predominantly over 60s (younger patients are a cause for concern)
What are the causes of trigeminal neuralgia?
- idiopathic
- vascular compression of trigeminal nerve (classical of vascular trigeminal conflict)
- secondary to MS, space occupying lesion
How do you diagnose a vascular trigeminal conflict?
MRI
How does trigeminal neuralgia present?
- unilateral maxillary or mandibular division pain (typically not ophthalmic)
- stabbing pain that last 5-10s
- triggers include touch, wind, cold, chewing
- can be paroxysmal or have continuous pain
Define paroxysmal.
No pain between episodes
What symptoms differentiate trigeminal neuropathy from trigeminal neuralgia?
- pain on more than one division
- bilateral pain
- burning sensation
What symptoms differentiate trigeminal autonomic cephalagia from trigeminal neuralgia?
Vasomator component
Describe the appearance of a trigeminal neuralgia patient?
- older patient
- mask like face due to fear of trigger
- appearance of excruciating pain, can be unable to speak
- no obvious precipitating pathology
What red flags are associated with trigeminal neuralgia?
- younger patients under 40
- sensory deficit in facial region (hearing loss)
- other cranial lesions
What is the first line drug therapy for trigeminal neuralgia?
- carbamazepine (modified release)
- oxcarbazepine
- lamotrigine (slow onset)
What is the second line drug therapy for trigeminal neuralgia?
- gabapentin
- pregabalin
- phenytoin
- baclofen
What are the common side effects of carbamazepine?
- blood dyscrasias (thrombocytopenia, neutropenia, pancytopenia)
- electrolyte imbalances
- neurological deficits
- liver toxicity
- skin reactions
Which drugs can cause hyponatreamia when they interact with carbamazepine?
- PPIs
- diuretics
When is surgery indicated for trigeminal neuralgia?
- not usually recommended if patient is coping with therapeutic management without significant side effects
- considered when patient is at maximum dose therapeutically
- considered when younger patient as drug use would be considerable
What are the surgical options trigeminal neuralgia?
- microvascular decompression
- destructive central procedures
- stereotactic radiosurgery
- destructive peripheral neurectomies
Define allodynia.
Pain provoked by a stimulus that typically wouldn’t cause pain
What are complications that can occur post-surgery for trigeminal neuralgia?
- local effects from peripheral treatment
- sensory loss (corneal reflex, general sensation and hearing loss)
- motor deficits
What are the causes of painful trigeminal neuropathy?
- HZV
- trauma
- idiopathic
What are trigeminal autonomic cephalalgias?
- unilateral head pain (predominantly V1 branch)
- excruciating
- associated with cranial parasympathetic autonomic features ipsilateral to headache
What are common cranial parasympathetic autonomic features associated with TAC?
- conjunctival injection
- nasal congestion
- eyelid oedema
- ear fullness
- miosis/ptosis
What are TAC also known as?
- cluster headaches
- suicide headaches
What are the different types of TAC?
- cluster headache
- paroxysmal hemicrania
- SUNCT
Describe a cluster headache.
- pain in orbital and temporal
- attacks are strictly unilateral with rapid onset and rapid cessation
- typical duration 15mins to 3hours
- excruciating pain, patients often restless and agitated
- prominent ipsilateral autonomic symptoms
- associated migrainous symptoms include nausea, photophobia, phonophobia
Describe the frequency of cluster headaches.
- episodic most common
- bouts last 1-3 months with at least 1 month remission
- can be continuous pain between attacks
- 1-8 attacks a day
Describe paroxysmal hemicrania.
- pain in orbital and temporal
- attacks are strictly unilateral with rapid onset and rapid cessation
- typical duration 2-30 mins
- excruciating pain, 50% patients restless and agitated
- prominent ipsilateral autonomic symptoms
- associated migrainous symptoms
- often precipitated by bending or rotating head
Describe the frequency of paroxysmal hemicrania.
- chronic most common
- 2-40 attacks a day
What drug therapy is available for cluster headache?
- abortive attack (zolmatriptan or 100% oxygen)
- abortive bout (lidocaine injection/oral prednisolone)
- preventive (verapamil/lithium/topiramate)
- CGRP monoclonal antibodies
What drug therapy is available for paroxysmal hemicrania?
- no abortive treatment
- prophylaxis with indomethacin
- other alternatives are COX-2 inhibitors, topiramate
