“Tic Doloureau”

4.3 per 100,000

Slight female predominance : 1.74 t0 1

Peak incidence 60-70 y.o. Unusual before age 40 No racial prediliction

“Tic Doloureau”

Higher incidence with M.S. & HTN

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 Amyloid A-V malformation Pons Infarct Bony compression

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 SXs

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 100’s of times per day Pain :

Severe Stereotypical Sharp Stabbing Superficial Shock-like

Diagnostic History

1 or more of the nerve’s divisions Trigger factors:

Talking Shaving Smiling 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 & I would NOT do it

Differential List

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

Hemicrania

Treatment

Medical

Surgical

No Behavioral, unless it becomes a cause of Chronic Pain

Medical Treatment

Carbamazepine : ‘A’ Rec NNT = 2.5 (For trigeminal Neuralgia) NNH = 3.7 (For all diseases) 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 Immediate release (lasts about 6 hrs.) Extended release (lasts about 12 hrs.)

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

Other agents to try : ( Not listed in any order)

Baclofen : 10 m- 80 mg daily Dilantin Lamictal Neurontin Topamax Klonopin Orap Depakene

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

Can try a trial sans meds after “several” months symptom free (Think 4-6)

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

2 Types of trigeminal neuralgia A clinical DX 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.