Trigeminal Neuralgia and Trigeminal Autonomic Cephalalgias

Question 1

What is neuralgia

Answer 1

An intense stabbing pain that is usually brief but may be severe

Pain extends along the course of the affected nerve

Question 2

What causes neuralgia caused by

Answer 2

Usually caused by irritation of or damage to a nerve

Question 3

What nerves can neuralgia affect that mediate the sensation to head

Answer 3

Trigeminal

Glossopharyngeal and Vagus

Nervus intermedius

Occipital

Question 4

What are the main causes of Trigeminal neuralgia

Answer 4

idiopathic

Classical= vascular compression of the trigeminal nerve

Question 5

What are the Secondary causes of trigeminal neuralgia

Answer 5

Multiple sclerosis

Sapce occupying lesion

Skull base deformity

connective tissue disease

Arteriovenous malformation

Question 6

What is the presentation of trigeminal neuralgia

Answer 6

Unilateral maxillary or mandibular pain (more likely than the ophthalmic division)

Its a stabbing pain that lasts 5-10s and is Purely paroxysmal or with concomitant continuous pain

Question 7

What can the triggers of trigeminal neuralgia be

Answer 7

Wind, cold, touch, chewing

Question 8

What may a typical patient with trigeminal neuralgia look like

Answer 8

Usually older with a mask like face and the appearance of excruciating pain with no obvious pathology

Question 9

What would be a red flag wit a patient presenting trigeminal neuralgia

Answer 9

> 40yrs

Sensory deficit in facial region or hearing loss

Always test the CN’s and ALL patients now must get MRI

Question 10

What is the first line drug therapy for TN

Answer 10

Carbamazepine

Oxcarbazepine

Lamotrigine

Question 11

What is the second line drug therapy for TN

Answer 11

Gabapentin

Pregabalin

Phenytoin

Baclofen

Question 12

What is the mangement of TN

Answer 12

Should be responsive to Carbamazepine and a pain diary can be useful

Question 13

What are the side effects of Carbamazepine

Answer 13

Blood dyscrasisas
-Thrombocytopenia
-Neutropenia
-Pancytopenia

electrolyte imbalances (hyponatreamia)

Neurlogical deficits
-Paraesthaesia
-Vestibular problems

Liver toxcity

Skin reactions

Question 14

When would there be surgery indications for TN

Answer 14

when approaching maximum tolerable medical management even if pain controlled

Younger patients with significant drug use – will have many years of drug use

Question 15

What are the surgical options for TN

Answer 15

Micro-vascular decompression

Destructive Central procedures

Stereotactic Radiosurgery

Destructive peripheral Neurectomies

Question 16

What is the preferred surgical treatment of TN

Answer 16

Microvascular decompression but it does require a vessel impinging on the Trigeminal nerve root

Question 17

What complications can happen after surgery

Answer 17

Local effects –peripheral treatments (cryotherapy)

Sensory loss
-Corneal reflex
-General sensation
-Hearing loss

Motor deficits

Question 18

What can the cause of painful trigeminal neuropathy be

Answer 18

Herpes Zoster Virus (related to active VZV infection, post-herpetic ‘neuralgia’)

Trauma (pain develops <6 months of traumatic event)

Idiopathic

Question 19

What are the characteristics of painful trigeminal neuropathy

Answer 19

pain is localized to the distribution of the trigeminal nerve

commonly described as burning/squeezing/pins-and-needles

primary pain is usually continuous or near-continuous

more commonly accompanied by clinically evident cutaneous allodynia and/or sensory deficits

Question 20

What is Trigeminal Autonomic Cephalalgias

Answer 20

Unilateral head pain
predominantly V1

Very severe / Excruciating

Usually prominent cranial parasympathetic autonomic features:
-Conjunctival injection
-Nasal congestion
-Eyelid oedema
-Ear fullness
-Miosis and ptosis (Horner’s syndrome)

Attack frequency and duration differs

Question 21

What types of headaches can TAC be

Answer 21

Cluster headache

Paroxysmal hemicrania

SUNCT

Question 22

What are cluster headaches

Answer 22

Excruciatingly severe
Pain mainly orbital and temporal

Attacks are strictly unilateral with
Rapid onset and the
Duration 15 mins to 3 hours with Rapid cessation of pain

Patients are restless and agitated during an attack

Prominent ipsilateral autonomic symptoms

Migrainous symptoms often present

Question 23

What are the cluster headache bouts like

Answer 23

Episodic in 80-90%

Attacks cluster into bouts typically 1-3 months with remission lasting at least 1 month

Attack frequency: 1 every other day to 8 per day

May be continuous background pain between attacks

These attacks have Striking circadian periodicity and appear same time each day and year

Question 24

What is Paroxysmal Hemicrania

Answer 24

Excruciatingly severe Pain mainly orbital and temporal

Attacks are strictly unilateral with Rapid onset and
Duration 2-30 mins with Rapid cessation of pain

They have 2-40 attacks per day

Prominent ipsilateral autonomic symptoms

Migrainous symptoms may be present

Background continuous pain can be present

80% have chronic PH, 20% have episodic PH

Question 25

What is the treatment of PH

Answer 25

Absolute response to indometacin

Question 26

What is the treatment of clust headache

Answer 26

Abortive (attack)
-Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg
-100% oxygen 7-12 l/min via a non-rebreathing mask

Abortive (bout)
-Occipital depomedrone/lidocaine injection
-Or tapering course of oral prednisone

Preventative
-Verapamil
-Lithium
-Methysergide
-Topiramate

Question 27

What is the treaetment of PH

Answer 27

No abortive treatment

prophylaxis with idomethacin

Alternatives – COX-II inhibitors, Topiramate