Constitutional problems: Fatigue, headache, dizziness

Question 1

Fatigue

Ddx

Answer 1

Question 2

Insomnia

Patient sleep hygiene advice

Answer 2

Sleep hygiene and routine:
* Do not try too hard in attempting to go to sleep. The more you worry about sleeping, the harder it will be for you to sleep.
* Establish a routine to follow before going to bed. Define clear sleeping hours and avoid daytime napping
* Go to bed to sleep (not to read, eat or watch television).
* Only lie down to go to sleep when you feel sleepy.
* Do not try to sleep immediately when anxious, after a heavy meal, after difficult work that required a lot of concentration, after strenuous exercise or after an emotional upset or argument.
* EXERCISE regularly—but avoid exercising too close to bed time as it may keep you awake
* Settling/ ‘WIND DOWN’ techniques: glancing through a magazine, listening to the radio, having a warm (not too hot) bath or shower, or some other relaxation technique.
* Avoid caffeine, alcohol and smoking
* Improve environment: quiet, dark and relaxing and avoid exposure to bright light in the morning.*

Question 3

Insomnia approach

Answer 3

Stepped care:
- Assess physical or mental health problems
- Monitor sleep pattern, sleep efficiency (% time asleep vs time in bed)
- Provide sleep hygiene advice
- Provide CBT approach: formulation of interaction between thoughts, physiology, emotions and behaviours relating to sleep. Relaxation, sleep restriction techniques.
- Consider hypnotic ( only when it is severe, disabling, or causing the patient extreme distress)
- Review and repeat assessment

Question 4

Insomnia

Hypnotics prescription indication, risk, choice

Answer 4

Indication:
- insomnia is severe and disabling
- prescribed for short periods (less than 4 weeks)
- should not be used every night
- Intermittent dosing is recommended
- Continue to asses adverse effects, history of substance abuse or dependence
- Discontinue by tapering off with concomitant CBT
- Hypnotics should be withdrawn gradually following chronic use because abrupt withdrawal may produce rebound symptoms of insomnia & agitation

Risk:
- potential for ataxia and consequent falls, particularly in the elderly
- sedation, hangover effect, affecting driving and performance of skilled tasks
- Abuse and dependence

Choice:
- Sleep-onset insomnia: Zopidem
- Maintaining sleep: Zopiclone or Temazepam
- Switching from one hypnotic to another should only occur if a patient experiences adverse effects

Question 5

Headache

Common ddx
Red flag signs

Answer 5

• Systemic upset (constitutional symptoms): CNS infection, Neoplasia, Vasculitis
• Neurological S/S: Intracranial pathologies
• New, Sudden onset: Temporal arteritis, SAH, Anneurysms, Dissections, Hypertensive crises, Acute optic neuritis, acute glaucoma, hydrocephalus
• Associated symptoms: trauma (haematoma), vomiting (ICP), Rash (meningococcus), Visual (glaucoma)
• Progression or Persistent despite treatment

Question 6

Headache

Ddx primary headache

Answer 6

Tension type headache
Migraine
Cluster headache
Giant arteritis
Trigeminal neuralgia

Question 7

Medication overuse headache

Diagnostic criteria

Answer 7

Question 8

Headache

• Diagnostic approach

Answer 8

Approach:
- Diagnose type of headache by clincal feature
- Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance
- explanation of the diagnosis and reassurance that other pathology has been excluded
- Discuss options for management
- recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers

Headache diary for diagnosis of primary headache for 8 weeks:
* frequency, duration and severity of headaches
* any associated symptoms
* all prescribed and over the counter medications taken to relieve headaches
* possible precipitants
* relationship of headaches to menstruation

Question 9

Headache

Red flag presentation/ reasons for referral

Answer 9

Consider further investigations and/or referral for people who present with new-onset headache and any of the following:
* compromised immunity, caused, for example, by HIV or immunosuppressive drugs
* age under 20 years and a history of malignancy
* a history of malignancy known to metastasise to the brain
* vomiting without other obvious cause

Question 10

Headache

frequency of headache to guide diagnosis

Answer 10

Question 11

Migraine with aura

• Clinical features
• Types of atypical aura

Answer 11

Aura: neurological symptoms that are:
* fully reversible
* develop gradually, either alone or in succession, over at least 5 minutes
* last for 5–60 minutes

Types of aura:
Visual (99%):
* Scotoma (-ve): gradually spreading visual defect, often bordered by fortification spectra
* Fortification spectra (+ve): shimmering, silvery zig-zag lines that march across visual fields

Sensory: (31%): tingling (+ve) followed by numbness (-ve) spreading from one part of the body to another

Aphasic (18%): transient speech disturbance due to dominant hemisphere involvement

Motor (6%): hemiplegic aura

Atypical aura: Consider further investigations and/or referral
* motor weakness
* double vision or visual symptoms affecting only one eye
* poor balance
* decreased level of consciousness.

Question 12

Menstrual-related migraine

Diagnostic criteria

Answer 12

Question 13

Tension type headache

Acute and prophylatic treatment

Answer 13

Question 14

Migraine with/without aura

Acute and prophylatic treatment

Answer 14

Acute treatment:
- Combination oral triptan and NSAID
- Combination oral triptan and paracetamol
- Nasal triptan for young person aged 12-17
- Monotherapy: oral triptan, NSAID, Aspirin (900mg), Paracetamol
- Additional: Anti-emetic
- Refractory: non-oral preparation of metoclopramide/ prochlorperazine + non-oral NSAID/ triptan
- Do not offer ergots or opioids for the acute treatment of migraine

Prophylactic treatment:
- Topiramate or propranolol or amitriptyline
- Riboflavin (400 mg once a day)
- Refractory: consider a course of up to 10 sessions of acupuncture over 5–8 weeks
- Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment
- Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives
- Do not offer gabapentin for the prophylactic treatment of migraine

Question 15

Menstrual-related migraine or migraine during pregnancy

Treatment

Answer 15

Menstrual-related migraine:
- Standard acute treatment options: Oral triptan +/- NSAID or paracetamol
- Frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected

Migraine during pregnancy
- Triptan or NSAID
- Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy

Question 16

Cluster headache

Acute treatment and prophylactic treatment

Answer 16

Acute treatment:
- Discuss need for neuroimaging for first episode of cluster headache
- Oxygen therapy: 100% oxygen at a flow rate of at least 12 litres per minute with a non-rebreathing mask and a reservoir bag + arrange home and ambulatory oxygen
- Subcutaneous or nasal triptan: dose based on history of cluster bouts and manufacturer’s max dose
- Intranasal lidocaine (administered ipsilaterally)
- Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache

Prophylactic treatment:
- Verapamil with ECG monitoring beforehand
- Short course oral corticosteroids
- Other drugs: topiramate, methysergide, gabapentin, Lithium
- Seek specialist advice for cluster headache that does not respond to verapamil

Question 17

Medication overuse headache

Treatment approach

Answer 17

• Withdraw overused medication
• Stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually
• headache symptoms are likely to get worse in the short term due to withdrawal
• Consider prophylactic treatment for the underlying primary headache disorder: use of steroids may aid withdrawal and for those who have an underlying headache disorder such as migraine or tension-type headache
• Do not routinely offer inpatient withdrawal for medication overuse headache
• Consider specialist referral and/or inpatient withdrawal of overused medication for people who are using strong opioids or failed withdrawal
• Review the diagnosis of medication overuse headache and further management 4–8weeks after the start of withdrawal

Question 18

Dizziness

Common causes

Answer 18

Question 19

4 main types of dizziness

Differentiate the 4 types’ description

Answer 19

Nonspecific lightheadedness (無法分辨) = most common
- Vague, doesn’t fall
- Ddx: Hyperventilation, Hypoglycemia, Anemia, Head trauma, Psychogenic (e.g. depression, anxiety)

Pre-syncope (快昏倒了)
- Impeding faint/ LOC +/- generalised weakness
- Postural change
- Worse in morning
- Ddx: Orthostatic hypotension, Autonomic dysfunction, Anti-hypertensive/ Anti-arrhythmic medication

Disequilibrium (走路不穩)
- Impaired balance and gait
- No abnormal head sensation/ no illusion or movement or faintness
- Ddx: Ageing multisensory deficit, Peripheral neuropathy, Musculoskeletal disorders, Gait disorders, Parkinson’s disease

Vertigo (天旋地轉)
- Hallucination of movement
- Typically rotatory

Question 20

Ddx non-specific light-headedness

Answer 20

 Hyperventilation
 Hypoglycaemia
 Anaemia
 Head trauma
 Associated with psychogenic disorders (e.g. depression, anxiety, phobia)

Question 21

Peripheral vs central vertigo

Compare onset and duration
Fatigability
Effect of gaze on vertigo
Associated symptoms

Answer 21

Peripheral = Acute onset and short duration, subsides in days

• Visual fixation helps suppress vertigo
• Fatigable vertigo: gets better after repeated episodes
• Severe nausea and vomiting
• Otological symptoms e.g. labyrinthitis
• Mild instability only

Central = Subacute/ slow onset with long duration, persistent

• Visual fixation does not suppress vertigo
• Not-fatigable: persistently same severity
• Variable nausea and vomiting
• Neurological symptoms
• Severe instability (can’t stand)

Question 22

Causes of peripheral vertigo

Answer 22

In semicircular canals and vestibule:

1) Benign paroxysmal positional vertigo (BPPV) = commonest
2) Meniere’s Disease
3) Perilymph fistula
4) Labyrinthitis
5) Superior canal dehiscence
6) Vestibular insufficiency
7) Ototoxicity
8) Trauma (fracture temporal bone / vestibular concussion)

In vestibular nerve:

1) Vestibular neuritis/ neuronitis
2) Vestibular paroxysmia (vascular loop compression of CN VIII)

Question 23

Causes of central vertigo

Answer 23

a) Central-vestibular vertigo (lesion of brainstem/ cerebellum, e.g. CVA/ tumour)
b) Migrainous vertigo
c) Cerebellar ataxia (e.g. infarction, Wilson’s disease, congenital)
d) Metabolic (dysthyroid, anaemia, electrolyte, hypoglycemia)
e) Medication (e.g. phenytoin overdose)

Question 24

BPPV

Pathogenesis
Clinical presentation

Answer 24

Most commonly affects posterior semicircular canal

Etiology – canalolithiasis:
- Particulate from otoconia (for saccule or utricle) is
dislodged (after head injury/ idiopathic) then stuck in
posterior semicircular canal
- Inertia of crystal continues to stimulate the ampulla

Presentation:
 True vertigo provoked by turning over to particular position in bed or when reaching up

 No hearing symptom (cochlea not affected; no infection)

 Usually lasts for ~3 weeks

Question 25

BPPV

Specific clinical test for diagnosis
Treatment

Answer 25

Diagnosis: Dix- Hallpike’s maneuver

Series of postural changes:
- settling particles from otoconia in posterior semicircular canal should stimulate ampulla
- eyes should have torsional nystagmus (down-beating vertically towards the ground)

Treatment:
- Epley’s Maneuvre: make crystals in semicircular canal move anteriorly and drop into utricle
- Reassurance
- Spontaneous recovery:
o 45deg propped up or 2 high pillows
o Not to sleep on the side of the bad ear
o Keep the head still at vertical position (i.e. not bent forward/backward)

Question 26

Meniere’s Disease

Pathogenesis
Specific signs

Answer 26

idiopathic syndrome of endolymphatic hydrops:
- overaccumulation of endolymph fluid in inner ear increase
endolymphatic pressure + malabsorption of endolymph
- physical distortion (bulging) of membranous labyrinth (distension of scala media)

Distension of saccule causes:

i. Hennebert’s sign (pressure on tragus induces vertigo)
ii. Tullio phenomenon (sound induce vertigo)

Micro-ruptures of membranous labyrinth causes episodic, recurrent attacks

Question 27

Meniere’s disease

Triad of clinical symptoms

Conditions to exclude in Dx

Answer 27

triad: vertigo, tinnitus, hearing loss +/- aural fullness

Rule out DDx of endolymph hydrops first:
Metabolic
 Hyperglycemia
 Hyperlipidemia
 Hypothyroidism

Infectious
 Syphilis
 Viral – measles, mumps

Autoimmune: SLE, RA

Development: Mondini dysplasia

Advanced otosclerosis with cochlear involvement

Question 28

Define diagnostic criteria for definite meniere’s disease

Prognosis

Answer 28

 >2 spontaneous episodes of vertigo lasting 20 min to 12 hours

 Audiometrically (pure tone audiogram) documented low- to medium-frequency sensorineural hearing loss in one ear around vertigo episode

 Fluctuating aural symptoms (hearing, tinnitus or aural fullness) in the affected ear

 Not better accounted by another vestibular diagnosis

Prognosis:
High spontaneous remission rate: >50% within 2 years; >70% after 8 years

Question 29

Define diagnostic criteria for Probable meniere’s disease

Answer 29

 >2 episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours (longer duration than definite Dx)

 Fluctuating aural symptoms (hearing, tinnitus or aural fullness) in the affected ear (same as definite dx)

 Not better accounted for by another vestibular diagnosis (same as definite dx)

 no pure tone audiogram = cannot make definite Dx

Question 30

Meniere’s disease

Acute treatment and chronic prophylaxis

Answer 30

Acute treatment:
 Vestibular sedatives:
cinnarizine, diazepam (benzodiazepine)

 Antiemetics: maxolon (= metoclopramide, dopamine receptor antagonist)), stemetil, ondansetron (5HT3 receptor antagonist)

 Intratympanic steroid injection

Chronic prophylaxis:
Lifestyle:
 Avoid caffeine
 Quit smoking
 Low salt diet, diuretics to reduce sodium load

Betahistine:
 Inner ear vasodilation = improve inner ear circulation
 Contraindicated for peptic ulcer / asthma

Surgical:
Intratympanic gentamicin injection (medical labyrinthectomy)
Less commonly performed:
o Endolymphatic sac decompression
o Labyrinthectomy
o Vestibular neurectomy

Question 31

Vestibular neuritis/ neuronitis

Cause
S/S
Tx

Answer 31

Cause: Post-viral infection, swelling of vestibular nerve

S/S:
 Sudden severe vertigo
 Nausea, vomiting
 Gait instability
 Hearing usually spared
 Poor caloric response in the involved ear
 Positive head thrust test@ in the direction of the involved side

Tx: self-limiting in days, unsteadiness for 3 months max
vestibular sedative, stemetil (antiemetic) for acute phase

Question 32

Perilymph fistula

Preceding causes
Pathogenesis
S/S
Tx

Answer 32

Causes:
 Cholesteatoma
 Trauma (including barotrauma)
 Iatrogenic (e.g. stapedectomy)
 Idiopathic
Pathogenesis:
Violation of barrier between middle and inner ear (most commonly round window/ oval window)

S/S:
 Vertigo onset after trauma
 Episodic vertigo attacks – worse on straining
 Fluctuating hearing loss

Tx: Urgent surgical repair of fistula

Question 33

Suppurative
labyrinthitis

Cause
S/S
Tx

Answer 33

Cause: Direct invasion of the inner ear by bacteria

S/S:
 Severe vertigo
 Hearing loss
 Ear discharge

Tx:
 Hospitalization
 Hydration
 Vestibular suppressants (stemetil)
 IV antibiotics
 Early surgical treatment of underlying CSOM/ cholesteatoma

Question 34

Toxin labyrinthitis

Preceding causes
S/S

Answer 34

Causes:
 Acute/chronic otitis media; or
 Early bacterial meningitis
Toxins penetrate the round window/ IAC/ cochlear aqueduct

S/S:
 Mild vestibular dysfunction
 Mild high-frequency hearing loss

Tx: Abx

Question 35

Herpes zoster oticus

Cause
S/S
Diagnostic test
Tx

Answer 35

Cause:
Reactivation of varicella zoster

S/S:
Ramsay Hunt syndrome:
 Vesicles on pinnae/ external auditory canal
 Facial weakness/ paralysis
 Sensorineural hearing loss
Diagnosis:
 Clinical presentation
 Culture of vesicular
fluid (HSV)

Tx:
 Antiviral therapy (acyclovir)
 Steroids
 Analgesics

Question 36

Outline history taking questions for dx of dizziness

Answer 36

Type: nonspecific lightheadedness, presyncope, postural imbalance, spinning vertigo

Time course
- Episodic attack/ sustained acute/ sustained chronic

Triggering factors
e. g. social situation, bright light, URTI..etc

Associated symptoms
e. g. Meniere’s triad, photophobia, cerebellar signs

Question 37

List triggers for :

BPPV
Migrainous vertigo
Vestibular neuritis
Perilymph fistula
Superior canal dehiscence
Vestibulopathy

Answer 37

Supine/ sleep on specific side: BPPV

Bright light (photophobia): Migrainous vertigo

URTI (viral infection): Vestibular neuritis/neuronitis

Head injury, Post-concussion, fractured temporal bone
 perilymph fistula, BPPV

Loud sound/ ear pressure
 Perilymph fistula
 Superior canal dehiscence

Ototoxic drugs (antibiotics, chemotherapeutics, e.g. cisplatin) Vestibulopathy

Question 38

Outline P/E for ddx cause of dizziness

Answer 38

Neurological exam for vision, proprioception

Vestibular causes:

• Otoscopy: r/o middle ear infection, cholesteatoma…etc
• Pure tone audiogram (Definite Meniere’s)
• Dix-Hallpike (BPPV)
• Fistula test (perilymph fistula, superior canal dehiscence)
• Central causes:

Cerebellar signs
* CN exams: Wallenberg/ Lateral medullary
* Gait exam
* HINTS: Head-Impulse test, Nystagmus, Test of Skew
* Motor: Romberg test

Question 39

Function of HINTS test to investigate dizziness

Answer 39

Rule out central causes of dizziness (untreated = high mortality)

HINTS:
1) Head-impulse test
2) Nystagmus (test with Frenzel goggles to eliminate visual fixation)
3) Test of Skew (detect skew deviation of eye by alternating cover test)

Question 40

Investigations for cause of dizziness (after clinical tests)

Answer 40

Imaging/ radiological for central causes:
o CT/MRI Brain & Brainstem
o MRI brain and internal auditory canal (with contrast) - acoustic neroma

Audiological tests if not sure peripheral/ dx definite Meniere’s
o Pure tone audiometry
o Electronystagmography (ENG) with caloric test or rotary chair
o Posturography

Question 41

Treatment of chronic vestibular insufficiency

Answer 41

Vision: wear glasses, treat cataracts…

Proprioception: use walking stick, physiotherapy

Vestibular: Vestibular sedatives for acute attack, Betahistine (meniere’s), Cawthorne-Cooksey exercises

Central: Move slower

Motor: Physiotherapy for motor training, TaiChi, yoga

Question 42

Secondary headache causes

Answer 42

Raised ICP

Meningitis

Temporal arteritis

Subarachnoid hemorrhage

Cervical spondylosis

Others:

Vascular: carotid/vertebral dissection, hypertensive crisis, vasculitis
CSF: CSF hypotension, post-LP headache
Other cranial structures: acute glaucoma, head trauma, neuralgia (post-herpetic, trigeminal, occipital)

Question 43

Features of Tension-type headache

Answer 43

• Bilateral, generalized, radiate forwards from occipital region
• Band-like tightness lasting for hours to weeks, recur often
• No associated symptoms, pt can carry on with activities
• Time course: last for hours to days or even months → May be episodic or chronic (persist over years)

Wax and wane, worse on touching scalp and worse in later part of day
Can be associated with anxiety/depression/ stress

Question 44

Features of migraine

Answer 44

Unilateral severe and Pulsatile/ Throbbing pain for 4-72h
20% preceded by aura (99% visual, 31% sensory, 18% aphasic, 6% motor)
Associated with photophobia, phonophobia, nausea/vomiting
Debilitating (worsens by movement) → lies in a quiet, dark room

Question 45

Features of Cluster headache

Answer 45

Severe, unilateral periorbital pain for 15-180 min
Strikingly periodic – begin at same hour for consecutive days over weeks
Associated with autonomic features eg. unilateral lacrimation, nasal congestion, conjunctival injection, Horner’s syndrome (~30-50%)
highly agitated during attacks

Question 46

Features of temporal arteritis

Answer 46

Persistent unil/bil temporal headache in pt >50y/o
Associated with temporal tenderness, jaw claudication, diplopia or amaurosis fugax
Jaw claudication - pain in proximal jaw near TMJ after brief chewing of tough food

Question 47

Ddx types of headache with bilateral vs unilateral involvement, ocular or facial involvment

Answer 47

→ Bilateral (TTH, ↑ICP, …) vs unilateral (migraine, cluster, temporal arteritis, trigeminal)
→ Ocular: ocular diseases (eg. acute glaucoma), trigeminal autonomic cephalalgias (TACs), lesions at apex of orbit or cavernous sinus (rare)
→ Facial: trigeminal neuralgia, herpes zoster, post-herpetic neuralgia, dental/TMJ diseases, sinusitis

Question 48

First line investigations for headache

Answer 48

P/E: Full neurological exam + H&N exam (skull, C-spine, teeth, ENT, sinuses, eyes) + BP

Investigations: for suspected serious secondary cause:

CBC, L/RFT for systemic disease
ESR
Plain XR e.g. CXR
CT/MRI brain (neurological deficits or seizures)
Vascular imaging
LP CSF analysis (infective or infiltrative)
ENT evaluation

Question 49

Migraine complications

Answer 49

• Chronic migraine if ≥15d/mo for >3mo w/o medication overuse
• Status migrainosus: debilitating migraine attack lasting for >72h
• Persistent aura w/o infarction: if aura lasts for >1w
• Migrainous infarction: aura symptoms lasting for >1h + ischaemic infarct on CT/MRI
• Migraine-triggered seizure: epileptic seizure occur during or ≤1h of aura

Question 50

Migraine triggers

Answer 50

→ Dietary: alcohol, chocolate, tyramine-containing (eg. dairy products), starvation, caffeine
→ Hormonal: often premenstrual or related to OCP (fluctuation in oestrogen)
→ Emotional: stress, anger, excitement
→ Others: change in sleep, irregular meals, certain drugs, smoking, fluorescent lights,
weather

Question 51

Triptans

Indication
MoA
S/E
C/I

Answer 51

Indication: Severe migraine headache
MoA: 5HT1 agonist → vasoconstriction, peripheral neuronal inhibition, ↓trigeminal neurotransmission
S/E: dizziness, somnolence, asthenia, nausea
C/I: IHD, stroke, CAD, uncontrolled HTN

Question 52

Ergotamine

Indication
MoA
S/E
C/I

Answer 52

Indication: Severe migraine headache
MoA: 5HT1 agonist → vasoconstriction, ↓trigeminal neurotransmission
S/E: vascular events (sustained generalized vasoconstriction), high risk of overuse syndrome and rebound headache
C/I: IHD, thyrotoxic heart disease, PVD, uncontrolled HTN

Question 53

Giant cell arteritis

Clinical features

Answer 53

□ Headache: new onset, bitemporal, intense throbbing headache

□ Neurological S/S:
Stroke, hearing loss, myelopathy, neuropathy
Blindness due to acute ischaemic optic neuropathy (AION)

□ Jaw claudication: pain when chewing or talking due to ischaemia of masseter

□ Visual S/S: amaurosis fugax (transient), can progress into permanent blindness (sight-threatening)
Due to arteritic acute ischaemic optic neuropathy (AAION)

□ Systemic S/S:
Fever, anorexia, malaise
Polymyalgia rheumatica (50%): pain and stiffness over shoulder and pelvic girdle muscles

Question 54

Giant cell arteritis

Diagnosis
Treamtent

Answer 54

Diagnostic criteria: ≥3 criteria

(1) Onset ≥50y
(2) New headache
(3) Abnormalities of temporal artery at PE: tender, thickened, non-pulsatile superficial temporal artery
(4) ↑ESR (>50mm/h)
(5) Abnormal findings on biopsy of temporal artery

Tx: urgent prednisolone 60mg qd

□ Urgent Tx prevents blindness and brainstem stroke and ↓headache
□ Parenteral high dose if complications already occurred
□ Gradual ↓dosage to maintenance level according to ESR level

Question 55

Trigeminal neuralgia

Causes
Treatment

Answer 55

Causes:
□ Classical TN:
→ Vascular loop compression: most common, 80-90%
→ Idiopathic

□ Other causes (secondary TN):
→ Multiple sclerosis, esp young and when bilateral
→ CPA masses: vestibular neuroma, meningioma, epidermoid cyst, AVM, angiomas…
→ Herpes zoster and post-herpetic neuralgia

Treatment:
Medical Tx: for classic TN
Carbamazepine (first-line, most effective, 75% responsive)

Surgical Tx: for refractory classic TN
* Peripheral neurectomy, eg. alcohol ablation (temporary relief)
* Microvascular decompression (separate vessels from trigeminal nerve root)
* Percutaneous radiofrequency thermocoagulation rhizotomy (artificial lesion for trigger spot on Trigeminal nerve)
* Treatment of underlying condition (eg. surgical decompression) for secondary TN