Trigeminal neuralgia

Question 1

Features & causes

Answer 1

Trigeminal neuralgia (‘tic douloureux’) is a condition of

• often unknown cause
• which typically occurs in patients >50 yrs,
• affecting the 2nd and 3rd divisions of the trigeminal nerve
• and on the same side of the face.

Brief paroxysms of pain, lasting on average 1–2 mins often with associated trigger points, are a feature.

Question 2

Trigeminal neuralgia: typical trigger points

Answer 2

Question 3

Treatment

Answer 3

Precise diagnosis is essential.

Pt education, reassurance and empathic support

• is very important.

Medical therapy:

Carbamazepine (from onset of attack to resolution) 50 mg (elderly patients)

• or 100 mg (o) bd initially,
• gradually ↑ dose to avoid drowsiness every 7 d to 200 mg bd (maintenance);
• or to a maximum of 600 mg bd

if carbamazepine not tolerated or ineffective (but question the diagnosis if lack of response):

• gabapentin 300 mg initially then increase as necessary
• lamotrigine 400 mg (o) daily
• clonazepam, phenytoin or sodium valproate

Surgery: refer to a neurosurgeon if medication ineffective.