Trigeminal Neuralgia & Trigeminal Autonomic Cephalalgias

Question 1

What is neuralgia?

Answer 1

• intense stabbing pain (brief but intense)
• extends along the course of the affected nerve
• usually caused by irritation or damage to a nerve

Question 2

What are some causes of trigeminal neuralgia?

Answer 2

• idiopathic (no cause)
• classical
• secondary

Question 3

What is classical trigeminal neuralgia?

Answer 3

vascular compression of the trigeminal nerve

Question 4

What are secondary causes of trigeminal neuralgia?

Answer 4

• multiple sclerosis
• space-occupying lesion
• skull base bone deformity
• arteriovenous malformation

Question 5

how does trigeminal neuralgia present?

Answer 5

• unilateral maxillary or mandibular devision pain
• stabbing pain
• 5-10 seconds duration (can be on its own or in clusters)

Question 6

What are some potential triggers for trigeminal neuralgia?

Answer 6

• cutaneous
• wind, cold
• touch
• chewing

Question 7

what is your typical trigeminal neuralgia patient?

Answer 7

• usually older
• ‘mask-like’ face
• appearance of excruciating pain
• NO obvious precipitating pathology

Question 8

What are some red flags in trigeminal neuralgia patients that may suggest something else is going on?

Answer 8

• younger patient (<40)
• sensory deficit in facial region (eg hearing loss)
• other cranial nerve lesions

Question 9

What are first line drugs for trigeminal neuralgia treatment?

Answer 9

• carbamazepine
• oxcarbazepine
• lamotrigine (slow onset of action)

Question 10

What second line drugs are used to treat trigeminal neuralgia?

Answer 10

• gabapentin
• pregabalin
• phytoin baclofen

Question 11

If a patient is having a trigeminal neuralgia attack in the chair, what can you do to help?

Answer 11

give local anaesthetic

Question 12

What side effects result from carbamazepine?

Answer 12

• thrombocytopenia or neutropenia or pancytopenia
• electrolyte imbalances
• paraesthesia
• liver toxicity
• skin reactions

Question 13

When should you consider surgery for trigeminal neuralgia management?

Answer 13

• when approaching maximum tolerable medical management even if pain controlled
• younger patients with significant drug use

Question 14

What surgical options are available for trigeminal neuralgia treatment?

Answer 14

• microvascular decompression
• destructive central procedures
• stereotactic radiosurgery
• destructive peripheral neurectomies

Question 15

what complications may arise from trigeminal neuralgia surgery?

Answer 15

• sensory loss (corneal reflex, general sensation, hearing loss)
• motor deficits

Question 16

What are other causes of painful trigeminal neuropathy aside from trigeminal neuralgia?

Answer 16

• herpes zoster virus
• trauma
• idiopathic

Question 17

What are characteristics of painful trigeminal neuropathy that is not trigeminal neuralgia?

Answer 17

• pain is localised to trigeminal distribution
• burning or squeezing or pins & needles
• pain is continuous or near continuous
• usually accompanied by clinically evident cutaneous allodynia

Question 18

what are the features of cephalalgic trigeminal neuralgia?

Answer 18

• unilateral head pain (v1)
• very severe/excrutiating
• prominent cranal parasympathetic aytonomic features

Question 19

What are examples of autonomic cephalalgic trigeminal neuralgia?

Answer 19

• cluster headache proxysmal
• paroxysmal hemicrania

Question 20

Where is the pain usually located in cluster headaches?

Answer 20

mainly orbital & temporal

Question 21

How do cluster headaches typically present?

Answer 21

• attacks are strictly unilateral
• rapid onset
• last 15 mins to 3 hours (majority are 45-90 mins)
• rapid cessation of pain

Question 22

How do cluster headache episodes present?

Answer 22

• attacks cluster in bouts typically 1-3 months with headaches & then 1 month remission
• attack frequently
• may have continuous background pain during a bout of attacks

Question 23

Where is the pain found in paroxysmal hemicrania?

Answer 23

• mainly orbital and temporal

Question 24

How does paroxysmal hemicrania differ from cluster headaches?

Answer 24

• last 2-30 mins
• 2 - 40 attacks per day
• 10% of attacks may be precipitated by bending or rotating their head
• 80% haft chronic PH

Question 24

What drug therapy is used to treat cluster headaches during an attack?

Answer 24

• subcutaneous sumatriptan 6mg
• nasal zolmatriptan 5mg
• 100% oxygen 7-12 l/min

Question 24

What drug therapy is used to treat cluster headaches during a bout of attacks?

Answer 24

• occipital depomedrone/lidocaine injection
• tapering course of oral prednisone

Question 25

What drugs are used to prevent cluster headaches?

Answer 25

• verapamil
• lithium
• methysergide
• topiramate

Question 26

What drug therapy is used to treat paroxysmal hemicrania?

Answer 26

• indomethacin
• COX-II inhibitors
• topiramate