Trigeminal Neuralgia & Trigeminal Autonomic Cephalalgies Flashcards
What is a neuralgia?
An intense stabbing pain
The pain is usually brief but may be severe
Pain extends along the course of the affected nerve
Usually caused by irritation of or damage to a nerve
Who is usually affected by trigeminal neuralgia?
Elderly patients in their 60’s or above
What are the classical causes of trigeminal neuralgia?
Vascular compression of the trigeminal nerve (most common known cause)
Needs to be evidence of actual compression to diagnose as this (MRI needed)
Termed vascular trigeminal conflict
What are some secondary causes of trigeminal neuralgia?
Multiple sclerosis
Spacy-occupying lesion (tumours-benign or malignant)
What does a patient with trigeminal neuralgia present with?
Unilateral maxillary or mandibular division pain usually as opposed to the ophthalmic division
A stabbing pain
5-10 second duration
–can also have a cluster of attacks lasting minutes
Purely paroxysmal (no pain in between attacks and symptom free) or with concomitant continuous pain (with superimposed stabbing attacks)
Patient experiences remissions and relapses
What are some triggers for trigeminal neuralgia?
Wind, cold
Touch
Chewing
What is the typical presentation of a patient with trigeminal neuralgia?
Usually older patient
‘mask-like’ face
–inexpressive face
Appearance of excruciating pain
No obvious precipitating pathology
What is the first line drug therapy for trigeminal neuralgia?
Carbamazepine- modified release formulations
–prolonged release one is particularly helpful to reduce side effects
Oxacarbazepine
Lamotrigine (slow onset of action)– only if not tolerated the first two
What is the second line drug therapy for trigeminal neuralgia?
Gabapentin
Pregablin
Phenytoin
Baclofen
What are some of the side effects of Carbamazepine?
Blood dyscrasias
–thrombocytopenia
–neutropenia
–pancytopenia
Electrolyte imbalances (hyponatraemia)
Neurological defects
–paraesthesia
–vestibular problems
–sensory deficits
Liver toxicity
Skin reactions
What should be carried out alongside prescribing carbamazepine?
Blood monitoring
Weekly for the first month and then on a monthly basis
Should include
FBC, Urea and electrolytes and a liver function test
What are the indications for surgery to treat trigeminal neuralgia?
Not usually recommended if patient is managing on medical therapy with moderate drug dose and no significant effects
Consider surgery
–When the patient is approaching the maximum tolerable medical management even if the pain is controlled
–Younger patients (in their 50’s) with significant drug use
What are the surgical options for trigeminal neuralgia?
Microvascular Decompression (MVD)
Stereotactic Radiosurgery
Destructive Central Procedures
Destructive Peripheral Neurectomies
What are some complications that can occur after trigeminal neuralgia surgery?
Local effects- peripheral treatments (cryotherapy)
Sensory loss
–corneal reflux
–general sensation
–hearing loss
Motor deficits
Can be reversible or irreversible
What can the causes of painful trigeminal neuropathy be?
Herpes Zoster Virus (related to active VZV infection- post herpetic neuralgia)
Trauma (pain develops within 6 months of traumatic event)
Idiopathic
