Trigeminal Neuralgia

INTRODUCTION:
  • It is the most debilitating form of neuralgia affecting the sensory branches of 5th C.N.
  • Disorder of peripheral or central fibres of Trigeminal nerve
  • In this there is sudden usually unilateral, severe, brief, stabbing,lancinating, recurring pain in the distribution of one or more branches of Trigeminal nerve
DEFINITION:
  • It is defined as sudden, usually unilateral, severe, brief, stabbing, lancinating, recurring pain in the distribution of one or more branches of the Vth cranial nerve
  • Trigeminal neuralgia also known as prosopalgia or fothergill’s disease is aneuropathic disorder characterized by episodes of intense pain in the face, originating from 
  • trigeminal nerve
ETIOLOGY:
  • Vascular compression
  • Usually idiopathic
  • Demylination of the nerve
  • Multiple sclerosis
  • abnormalities
  • Viral etiology
TYPES:
  • TYPICAL TRIGEMINAL NEURALGIA
  • ATYPICAL TRIGEMINAL NEURALGIA
  • PRE- TRIGEMINAL NEURALGIA
  • MULTIPLE SCLEROSIS RELATED TRIGEMINAL NEURALGIA
  • SECONDARY OR TUMOR RELATED TRIGEMINAL NEURALGIA
  • TRIGEMINAL NEUROPATHY OR POST-TRAUMATIC TRIGEMINAL NEURALGIA
  • FAILED TRIGEMINAL NEURALGIA
CLINICAL SYMPTOMS:
  • INCIDENCE 8:100000
  • AGE-5th-6th decade of life
  • SEX-female> male
  • AFFLICTION FOR SIDE- right> left
  • DIVISION OF TRIGEMINAL NERVE INVOLVEMENT- V3>V2>V1
  • Manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve
  • Pain is usually confined to one part of one division of trigeminal nerve
  • Pain rarely crosses the midline
  • Attacks do not occur during sleep common during day time
  • Pain is of short duration, but may recur with variable frequency.
  • In extreme cases, the patient will have a motionless face – the ‘frozen or mask like face’.
  • Common trigger zone include- cutaneous( corner of the lips, cheek, ala of the nose, lateral brow); intraoral( teeth, gingivae, tongue). Trigger area on the face are so 
  • sensitive that touching or even air currents can trigger an episode.
  • 10-12% of cases are bilateral, or occurring on both sides. This mainly seen in cases with systemic involvement include multiple sclerosis or expanding cranial tumor
DIAGNOSIS
  • From a well taken history
  • CT- scan
  • MRI
  • Diagostic nerve blockn
DIFFERENTIAL DIAGNOSIS:
  • MIGRAINE- severe type of periodic headache is persistent, at least over a period of hours and it has no trigger zone.
  • SINUSITIS- pain is not paroxysmal, in this pain is persistent, associated nasal symptoms.
  • DENTAL PAIN- localized, related to biting or hot or cold foods, visible abnormalities on oral examination.
  • Tumors of nasopharynx- in this similar type of pain is produced, manifested in the lower jaw, tongue and side of the head with associated middle ear deafness. This complex
  • lesion is called TROTTER’S syndrome. Patient exhibit asymmetry and defective mobility of the soft palate and affected side. As the tumor progresses, trismus of internal

  • pterygoid muscle develops, and patient is unable to open the mouth. Here actual cause of pain is involvement of mandibular nerve in the foramen ovale.
  • Post herpetic neuralgia- pain is usually involved in ophthalmic division. The history of skin lesion prior to onset of neuralgia, pain is persistent, associated nasal symptoms. TREATMENT
MEDICAL
  • First line of treatment is CARBAMAZIPINE ( anticonvulsant)
  • Second line of treatment is: BACLOFEN, LAMOTRIGINE, OXCARBAZEPINE, PHENYTOIN, GABAPENTIN, PREGABALIN, SODIUM VALPROATE
  • Low dose of Antidepressants such as AMITRYPTILINE are thought to be effective in treating neuropathic pain. Antidepressant are also used to counteract a medication side effect. DULOXETINE is helpful where neuropathic pain and depression are combined.
  • Opiates such as MORPHINE and OXYCODONE, there is evidence of their effectiveness on neuropathic pain, especially if combined with gabapentin, gallium maltoate in a cream or ointment base has been reported to relieve refractory postherpetic TN
SURGICAL
  • Long acting anesthetic agents
  • Alcohol injection
  • PERIPHERAL GLYCEROL INJECTION 
  • PERIPHERAL NEURECTOMY( NERVE AVULSION)
  • OPEN PROCEDURES ( INTRACRANIAL PROCEDURES) 
  1. MICROVASCULAR DECOMPRESSION
  2. PERCUTANEOUS RHIZOTOMIES
  3. GAMMA KNIFE RADIOSURGERY 
Exam Question
  • Vascular compression is the most common cause of trigeminal neuralgia
  • More common in female
  • more common on right side of face
  • Most commonly involve mandibular branch 
  • Nature of pain in trigeminal neuralgia is sharp, shooting, lancinating shock like and recurrent that precipitate on chewing
  • Attacks common during day time
  • First line of treatment is carbamazipine administration

Don't Forget to Solve all the previous Year Question asked on Trigeminal Neuralgia