Trigeminal Neuralgia and other causes of facial pain Flashcards
Trigeminal Neuralgia
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
Classifications TMN
- Idiopathic without disease
- Trigeminal root compression
- 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
Aetiology TMN
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
Pain history TMN
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
Management TMN
Carbamazepine 100mg bd for 2 weeks
Surgery:
1. Peripheral surgery
2. Intracranial surgery
3. Percutaneous surgery
4. Stereotactic gamma knife radiosurgery
Peripheral surgery
Cryosurgery of the affected branch of the nerve e.g., mental nerve/radiofrequency thermocoagulation
Intracranial surgery
Microvascular decompression has a good prognosis
Percutaneous surgery
Radiofrequency lesioning (risk of anaesthesia dolorsa)
Stereotactic gamma knife radiosurgery
80% pain control
Takes 6 weeks to work
Carbamazepine
Anticonvulsant
Pt responds to 200-400mg tds daily
Adverse effects – ataxia/drowsiness/visual disturbances/headaches/GI upsets/hypertension
Giant cell arteritis
Immunological/Vasculitic (inflammation of blood vessels) condition in which there is inflammation of medium sized arteries especially in the head and neck
Giant cell arteritis epidemiology
affects older patients
F>M
GAC CP
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
GAC Diagnosis
Clinical
Raised ESR (non specific mark of inflammation)
Arterial biopsy (numerous giant cells, deranged internal elastic lamina)
GAC management
systemic corticosteroids – prednisolone 60mg daily
Glossopharyngeal Neuralgia
Rare condition in which there are repeated episodes of severe pain in the tongue, throat, ear and tonsils.
GN CP
Severe paroxysmal pain in the posterior tongue/tonsillar region
pain may radiate to the ear
triggered by swallowing/coughing
nasopharyngeal malignancy similarities
GN Management
Carbamazepine
Periodic Migrainous Neuralgia
Cluster headaches
Unilateral
Excruciating pain
Early morning hours
PMN Epidemiology
M>F
Middle age
PMN CP
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
Management PMN
Oxygen therapy
Sumatriptan (nasal therapy)
PMN prophylaxis
Verapamil
Nifedipine
Ergotamine
Lithium
Paroxysmal headaches
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.
PH CP
Frequent, short lasting attacks of unilateral pain
Orbital, supraorbital or temporal region
5-40 attacks per day
PH associated autonomic symptoms
Conjunctival redness
Rhinorrhoea
Nasal congestion
Lacrimation
Ptosis
Eyelid oedema
PH Tx
Indometacin: NSAID
Persistent idiopathic facial pain (PIFP)
Constant chronic orofacial discomfort or pain, for which no organic cause can be found
PIFP Epidemiology
1-2% population
Older females (70%)
PIFP CP
Poor pain localised
multiple oral and other psychogenic related symptoms
psychogenic origin
PIFP Tx
Poor response
Tricyclic antidepressants as a first line eg. amitriptyline
Fluoxetine and venlafaxine
peripheral subcutaneous field stimulation may be alterative
Atypical facial pain
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.
AFP CP
Upper jaw pain, unrelated to distribution of trigeminal nerve
deep, dull, boring pain
persists for most of the day
does not disturb pain
AFP diagnosis
exclusion of organic disease
AFP management
Amitriptyline/Nortriptyline
Duloxetine
Gabapentin
CBT
Migraines
Often causes painful headaches
Migraines epidemiology
F>M
Common
Migraines CP
Recurrent, incapacitating, unilateral headaches
supraorbital
spontaneous remission
serotonin release – cerebral artery dilatation - increased midbrain grey matter metabolic activity
