Trigeminal Neuralgia and other causes of facial pain

Question 1

Trigeminal Neuralgia

Answer 1

Disorder of the trigeminal nerve that consists of episodes of unilateral, intense, stabbing, electric shock like pain in the areas of the face where the branches of the nerve are distributed

Question 2

Classifications TMN

Answer 2

1. Idiopathic without disease
2. Trigeminal root compression
3. Secondary: occurs in the presence of disease such as tumours of trigeminal nerve (neuromas), lesions affecting trigeminal nerve at cerebellopontine angle, MS and cerebral neoplasms

Question 3

Aetiology TMN

Answer 3

Uncertain neurological cause
? Due to pressure on the TN root in the posterior cranial fossa from an adjacent vessel pressing on the nerve root causing demyelination/neurological discharge
physical/emotional stress can increase frequency

Question 4

Pain history TMN

Answer 4

Sudden, sharp, severe stabbing pain
Last few seconds <2 mins
Attacks may be more common in the morning
Occurs spontaneously
Entirely asymptomatic between attacks
Unilateral
F>M

Question 5

Management TMN

Answer 5

Carbamazepine 100mg bd for 2 weeks
Surgery:
1. Peripheral surgery
2. Intracranial surgery
3. Percutaneous surgery
4. Stereotactic gamma knife radiosurgery

Question 6

Peripheral surgery

Answer 6

Cryosurgery of the affected branch of the nerve e.g., mental nerve/radiofrequency thermocoagulation

Question 7

Intracranial surgery

Answer 7

Microvascular decompression has a good prognosis

Question 8

Percutaneous surgery

Answer 8

Radiofrequency lesioning (risk of anaesthesia dolorsa)

Question 9

Stereotactic gamma knife radiosurgery

Answer 9

80% pain control
Takes 6 weeks to work

Question 10

Carbamazepine

Answer 10

Anticonvulsant
Pt responds to 200-400mg tds daily
Adverse effects – ataxia/drowsiness/visual disturbances/headaches/GI upsets/hypertension

Question 11

Giant cell arteritis

Answer 11

Immunological/Vasculitic (inflammation of blood vessels) condition in which there is inflammation of medium sized arteries especially in the head and neck

Question 12

Giant cell arteritis epidemiology

Answer 12

affects older patients
F>M

Question 13

GAC CP

Answer 13

Severe burning pain in distribution of the affected vessel - temporal/tongue/masticatory muscle region (claudication pain)
headache is intense, deep, aching, throbbing, persistent
worse lying flat in bed
affected artery may be enlarged and tender
jaw claudication (pain on chewing)
pain and necrosis in tongue or lip
retinal artery affected –> risk of blindness

Question 14

GAC Diagnosis

Answer 14

Clinical
Raised ESR (non specific mark of inflammation)
Arterial biopsy (numerous giant cells, deranged internal elastic lamina)

Question 15

GAC management

Answer 15

systemic corticosteroids – prednisolone 60mg daily

Question 16

Glossopharyngeal Neuralgia

Answer 16

Rare condition in which there are repeated episodes of severe pain in the tongue, throat, ear and tonsils.

Question 17

GN CP

Answer 17

Severe paroxysmal pain in the posterior tongue/tonsillar region
pain may radiate to the ear
triggered by swallowing/coughing
nasopharyngeal malignancy similarities

Question 18

GN Management

Answer 18

Carbamazepine

Question 19

Periodic Migrainous Neuralgia

Answer 19

Cluster headaches
Unilateral
Excruciating pain
Early morning hours

Question 20

PMN Epidemiology

Answer 20

M>F
Middle age

Question 21

PMN CP

Answer 21

Accompanied by ipsilateral lacrimation, conjuctival redness, photophobia, nasal stuffiness
vasodilation in extra cranial carotid arteries and increased hypothalamic activity
attacks may be precipitated by alcohol, high altitudes, hypoxia in REM sleep

Question 22

Management PMN

Answer 22

Oxygen therapy
Sumatriptan (nasal therapy)

Question 23

PMN prophylaxis

Answer 23

Verapamil
Nifedipine
Ergotamine
Lithium

Question 24

Paroxysmal headaches

Answer 24

Paraoxysmal hemicrania is a rare form of headache that usually begins in adulthood. Pts usually experience throbbing, claw like, boring pain usually on one side of their face.

Question 25

PH CP

Answer 25

Frequent, short lasting attacks of unilateral pain
Orbital, supraorbital or temporal region
5-40 attacks per day

Question 26

PH associated autonomic symptoms

Answer 26

Conjunctival redness
Rhinorrhoea
Nasal congestion
Lacrimation
Ptosis
Eyelid oedema

Question 27

PH Tx

Answer 27

Indometacin: NSAID

Question 28

Persistent idiopathic facial pain (PIFP)

Answer 28

Constant chronic orofacial discomfort or pain, for which no organic cause can be found

Question 29

PIFP Epidemiology

Answer 29

1-2% population
Older females (70%)

Question 30

PIFP CP

Answer 30

Poor pain localised
multiple oral and other psychogenic related symptoms
psychogenic origin

Question 31

PIFP Tx

Answer 31

Poor response
Tricyclic antidepressants as a first line eg. amitriptyline
Fluoxetine and venlafaxine
peripheral subcutaneous field stimulation may be alterative

Question 32

Atypical facial pain

Answer 32

Syndrome that encompasses a wide group of facial pain problems
Condition characterised by burning, aching or cramping sensation. Occurs on one side of the face, often in the region of the trigeminal nerve.

Question 33

AFP CP

Answer 33

Upper jaw pain, unrelated to distribution of trigeminal nerve
deep, dull, boring pain
persists for most of the day
does not disturb pain

Question 34

AFP diagnosis

Answer 34

exclusion of organic disease

Question 35

AFP management

Answer 35

Amitriptyline/Nortriptyline
Duloxetine
Gabapentin
CBT

Question 36

Migraines

Answer 36

Often causes painful headaches

Question 37

Migraines epidemiology

Answer 37

F>M
Common

Question 38

Migraines CP

Answer 38

Recurrent, incapacitating, unilateral headaches
supraorbital
spontaneous remission
serotonin release – cerebral artery dilatation - increased midbrain grey matter metabolic activity