Trigeminal

Neuralgia

Pedro Bernado

Trigeminal Neuralgia

4.3 per 100,000

Slight female

predominance : 1.74 t0
1
Peak incidence 60-70
y.o.
Unusual before age 40
No racial predilection

Trigeminal Neuralgia
Higher incidence with multiple

sclerosis and hypertension

Spontaneous remission possible,

BUT unusual
Most patients will have episodic

attacks over many years

Now 2 Types Are

Identified
Classical
Symptomatic

Classical Criteria
A. Paroxysmal attacks of pain lasting from a

fraction of a second to 2 minutes, affecting

1 or more divisions of the trigeminal nerve,
& fulfilling criteria B & C.
B. Pain has at least 1 of the following
characteristics:
1. Intense, sharp, superficial, or stabbing
Precipitated from trigger zones or by trigger

factors

Classical Criteria
C. Attacks are stereotyped in

the individual patient

D. No clinically evident neuro deficit
E. Not attributed to another disorder.

Symptomatic Criteria
A. Paroxysmal attacks of pain lasting from

a fraction of a second to 2 minutes, with or

w/o persistence of pain between
paroxysms, affecting 1 or more divisions of
the trigeminal nerve, & fulfilling criteria B
& C.
B. . Pain has at least 1 of the following
characteristics:
1. Intense, sharp, superficial, or stabbing
Precipitated from trigger zones or by trigger

factors

Symptomatic Criteria
C. Attacks are stereotyped

in the individual patient

D. A causative lesion, other than vascular

compression, has been demonstrated by

special investigations &/or posterior fossa
exploration.

Pathophysiology

Pathophysiology

Demyelination of the trigeminal nerve,

causing ectopic impulses and then ephaptic

conduction
Vascular compression of the nerve root by
aberrant or tortuous vessels
Compression by tumor
A-V malformation
Pons Infarct
Bony compression

Trigeminal Neuralgia
Signs/Symptoms
Abrupt onset of excruciating pain

-ophthalmic, maxillary, mandibular branches

Trigger zone/specific point stimulation along nerve
branches
-chewing,tooth-brushing,washing face, yawning,
talking, applying makeup, blast of cold or hot air in
face
Most common trigger is touch or tickle on face
Pain: burning/knife-like/ lightning shock in upper
and/or lower gum/cheeks, forehead, side of nose, lips

Diagnosis
Clinical
Consider in all patients with unilateral facial

pain
Prompt Dx important as pain can be severe
Distinguish classical from symptomatic for RX
purposes
Look for red flags of other diseases

Red Flags

Abnormal Neuro exam

Abnormal oral, dental, or ear exam

Age < 40 yrs
Bilateral
Dizziness or vertigo

Red Flags

Hearing loss
Numbness

Pain lasting > 2 minutes

Pain outside of trigeminal distribution
Visual changes

Diagnostic History

Very important
Recurrent, unilateral facial pain
Lasts seconds
May recur 100s of times per day
Pain :
Severe
Stereotypical
Sharp
Stabbing
Superficial
Shock-like

Diagnostic History
1 or more of the nerves divisions
Trigger factors:
Talking
Smiling

Shaving
Applying make-up
Chewing
Wind
Teeth brushing

Age > 40 yrs.

Ask about other neuro Sx
Asymptomatic time or not ?

Physical Exam
Usually a normal exam
Useful for identifying abnormals that point to

other DXs
HEENT, including TMJ & Masseter
Oral exam, including teeth & gums
Neuro exam
Check for trigger zones

Diagnostic Testing
Generally Not helpful
MRI is the Test of Choice : C Rec
Trigeminal reflex testing? Unclear

usefulness

Differential List
Cluster HA
Dental Pain
Giant Cell Arteritis
Migraine
Neuralgia
Otitis Media
Intracranial Tumor
Sinusitis
Multiple Sclerosis
TMJ Syndrome
Postherpetic Neuralgia
Glossopharyngeal

Treatment
Medical
Surgical
No Behavioral, unless it becomes a cause of

Chronic Pain

Medical Treatment
Carbamazepine : A Rec
Some suggest it as a diagnostic trial
Doses range from 100 to 2,400 mg per day
Most respond to 200 to 800 mg per day

Medical Treatment
Carbamazepine should be the

initial Rx of choice for classical

Trigeminal Neuralgia
If get no or only partial response

to carbamazepine, add or
substitute another
pharmacologic agent:

Medical Treatment

Medical Treatment
A recent Cochrane review said there was

insufficient evidence to show benefit from

non-epileptic agents in trigeminal neuralgia

Follow-up
Achieve balance between pain and med side

effects
Most want complete remission, which is
possible and warranted

Surgical Treatment
After failure of Pharm agents
Unusual
Recurrences occur for many
Both percutaneous & open techniques
Glycerol injection
Ballon Compression
Radio Rhizotomy
Gamma knife
Partial Rhizotomy
Microvascular
decompression

Summary
Two types of trigeminal

neuralgia
A clinical Diagnosis
Everyone gets a head & face
MRI
Carbamazepine is the treatment
of choice.

References

Kraft, RM. Trigeminal Neuralgia.

AFP. 2008;77:1291-1296.
Cochrane Collaboration
Haanpaa M, et al. Neuropathic
Facial Pain. Suppl Clin
Neurophysiol. 2006;58:153-170.