trigeminal neuralgia, autonomic headache and migraine Flashcards
What is neuralgia?
An intense stabbing pain
Usually brief but severe
Pain extends along the course of the affected nerve
Usually caused by irritation or damage to a nerve
Give 4 examples of nerves affected in cranial neuralgias
Any from:
- trigeminal
- glossopharyngeal
- vagus
- nervous intermedius
- occipital
What is the incidence of TN?
Affects 4.3 in 100,000 people
Female:male ratio is 5.9:3.4
What are the causes of TN?
Idiopathic
Classical - vascular compression of the trigeminal nerve
Secondary:
- multiple sclerosis
- space-occupying lesions
- others eg connective tissue disease, skull-base bone deformity
How does TN usually present?
Unilateral maxillary or mandibular division pain - more common than ophthalmic division
5-10 seconds duration
Purely paroxysmal (uncontrollable and sudden) or with continuous pain
Usually older patient
What are the triggers of TN?
Cutaneous
Wind and cold
Touch
Chewing
Describe the acute spasms of pain in TN
May be more than one division
May be bilateral
May have a burning component
May have a vasomotor component
What are the red flags of TN?
Younger patients (<40)
Sensory deficit in facial region - hearing loss
Other cranial nerve lesions
Always test cranial nerves to identify sensory deficit - pts all now get an MRI
What is the first line drug therapy for TN?
Carbamazepine - modified release
Oxycarbazepine
Lamotrigine - slow onset of action
What is the second line drug therapy for TN?
Gabapentin
Pregabalin
Phenytoin
Baclofen
How is TN managed?
Patient should be responsive to carbamazepine if they can tolerate it
Pain often difficult to control first thing in the morning
Pain diary helpful to identify modifications necessary to therapy
Maximise effects of drugs whilst minimising size effects
Patients can be responsive to LA
What are the side effects of carbamazepine?
Blood disorders - thrombocytopenia, neutropenia, pancytopenia
Electrolyte imbalances (hyponatreamia)
Neurological deficits - Paraesthesia, vestibular problems
Liver toxicity
Skin reactions (potentially life threatening)
When is surgery considered for TN?
When approaching maximum tolerable medical management even if pain is controlled
In younger patients with significant drug use
What are the surgical options for TN?
Microvascular decompression (MVD) - preferred treatment where possible
Stereotactic radiosurgery
Destructive central procedures
Destructive peripheral neurectomies
What are the complications of TN surgery?
Sensory loss - corneal reflex, general sensation and hearing loss
Motor deficits
These may be reversible or irreversible
What are the causes of painful trigeminal neuropathy?
Herpes Zoster Virus
Trauma
Idiopathic
What are the characteristics of painful trigeminal neuropathy?
Pain localised to the distributions of the trigeminal nerve
Commonly describes as burning or squeezing like pins and needles
Primary pain usually continuous or near continuous
Commonly accompanied by allodynia and sensory deficits
What is allodynia?
Pain due to a stimulus that does not normally provoke pain
What are trigeminal autonomic cephalalgias?
Unilateral head pain - predominantly from V1
Very severe, excruciating pain
Include cluster headache, paroxysmal hemicrania and SUNCT
For cluster headache, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?
1-8 daily
15-180 minutes
Sharp, throbbing pain
Very severe pain
70%
For paroxysmal hemicrania, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?
1-40 daily
2-30 minutes
Sharp, throbbing pain
Very severe pain
45%
For SUNCT, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?
3-200 daily
5-240 seconds
Stabbing, burning pain
Very severe pain
Circadian periodicity is absent
What is aura?
Neurological symptoms experienced before the onset of a headache
What is cluster headache known as and where is the pain usually?
Suicide headache
Pain mainly orbital and temporal
What are the symptoms of cluster headache?
Migraine symptoms - tiredness, yawning
Nausea
Vomiting
Photophobia (abnormal sensitivity to light)
Aura in 14% of patients
Where is the pain mainly for paroxysmal hemicrania?
Pain is mainly orbital and temporal
Attacks strictly unilateral
What drugs are used to treat cluster headache?
Abortive (attack) - sumatriptan or zolmatripan and 100% oxygen
Abortive (bout) - occipital lidocaine, oral prednisolone
Preventative - lithium, verapamil
CGRP - monoclonal antibodies
What drugs are used to treat paroxysmal hemicrania?
No abortive treatment
Prophylaxis with indomethacin
Alternatives - COX-II inhibitors, topiramate
