Neuropathic Pain: How to manage it

Question 1

Etiology and pathophysiology

Answer 1

Severe unilateral pain

• idiopathic
• compression of trigeminal root by tumours/vascular problems

Question 2

Presentation

Answer 2

Unilateral
Brief electric shock like pains
Evoked by light touch
-washing 
-shaving
-smoking
-talking
-teeth brushing
Pain that may remit

Question 3

What are red flags that may highlight a serious underlying cause

Answer 3

Sensory changes
Deafness, changes in hearing
Optic neuritis
History of skin, oral lesions that could spread perineurally
Pain only in opthalmic division of trigeminal
Bilateral pain
Onset before 40
FHx of MS

Question 4

Management of trigeminal neuralgia

Safety netting

Answer 4

FIRST LINE - carbamazepine
-failure to respond/atypical features => neurology referral

Surgery - microvascular decompression
Nerve ablation - radiofrequency, neurolysis, radiosurgery

Question 5

Neuropathic pain

-pathophysiology

Answer 5

Pain that results from nerve damage

• peripheral neuropathy - diabetes, chronic excess alcohol, HIV, chemo)
• compression neuropathy
• trauma
• central pain - stroke
• postherpetic neuralgia

Question 6

Neuropathic pain

-management

Answer 6

1st line - TCA or specific AEDs

• amitriptyline
• pregabalin/gabapentin

2nd line - opioids