Trigeminal Neuralgia and Trigeminal Autonomic Cephalalgias Flashcards
What is neuralgia
An intense stabbing pain that is usually brief but may be severe
Pain extends along the course of the affected nerve
What causes neuralgia caused by
Usually caused by irritation of or damage to a nerve
What nerves can neuralgia affect that mediate the sensation to head
Trigeminal
Glossopharyngeal and Vagus
Nervus intermedius
Occipital
What are the main causes of Trigeminal neuralgia
idiopathic
Classical= vascular compression of the trigeminal nerve
What are the Secondary causes of trigeminal neuralgia
Multiple sclerosis
Sapce occupying lesion
Skull base deformity
connective tissue disease
Arteriovenous malformation
What is the presentation of trigeminal neuralgia
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
What can the triggers of trigeminal neuralgia be
Wind, cold, touch, chewing
What may a typical patient with trigeminal neuralgia look like
Usually older with a mask like face and the appearance of excruciating pain with no obvious pathology
What would be a red flag wit a patient presenting trigeminal neuralgia
> 40yrs
Sensory deficit in facial region or hearing loss
Always test the CN’s and ALL patients now must get MRI
What is the first line drug therapy for TN
Carbamazepine
Oxcarbazepine
Lamotrigine
What is the second line drug therapy for TN
Gabapentin
Pregabalin
Phenytoin
Baclofen
What is the mangement of TN
Should be responsive to Carbamazepine and a pain diary can be useful
What are the side effects of Carbamazepine
Blood dyscrasisas
-Thrombocytopenia
-Neutropenia
-Pancytopenia
electrolyte imbalances (hyponatreamia)
Neurlogical deficits
-Paraesthaesia
-Vestibular problems
Liver toxcity
Skin reactions
When would there be surgery indications for TN
when approaching maximum tolerable medical management even if pain controlled
Younger patients with significant drug use – will have many years of drug use
What are the surgical options for TN
Micro-vascular decompression
Destructive Central procedures
Stereotactic Radiosurgery
Destructive peripheral Neurectomies
What is the preferred surgical treatment of TN
Microvascular decompression but it does require a vessel impinging on the Trigeminal nerve root
What complications can happen after surgery
Local effects –peripheral treatments (cryotherapy)
Sensory loss
-Corneal reflex
-General sensation
-Hearing loss
Motor deficits
What can the cause of painful trigeminal neuropathy be
Herpes Zoster Virus (related to active VZV infection, post-herpetic ‘neuralgia’)
Trauma (pain develops <6 months of traumatic event)
Idiopathic
What are the characteristics of painful trigeminal neuropathy
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
What is Trigeminal Autonomic Cephalalgias
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
What types of headaches can TAC be
Cluster headache
Paroxysmal hemicrania
SUNCT
What are cluster headaches
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
What are the cluster headache bouts like
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
What is Paroxysmal Hemicrania
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
What is the treatment of PH
Absolute response to indometacin
What is the treatment of clust headache
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
What is the treaetment of PH
No abortive treatment
prophylaxis with idomethacin
Alternatives – COX-II inhibitors, Topiramate
