Trigeminal neuralgia



Background

Distribution Trigeminal Neuralgia
  • Sudden and severe pain of trigeminal neuralgia as a lightning pain in the face.
  • "tic doloreux" describes the pain that may be triggered by touch or cold
  • Incidence 5 /100,000, Women > Men, Onset often after 60 years of age.
  • Bouts lasting weeks, remissions lasting months or years.
  • Probably caused by compression of the trigeminal nerve root, close to the pons, by an aberrant arterial or venous loop.
  • 1% have involvement of all three nerve branches.
  • About 2% of patients with trigeminal neuralgia have multiple sclerosis.

Differential Diagnosis

  • Dental infection or cracked tooth (well localised to tooth, local swelling and erythema).
  • TMJ pain (often bilateral, may radiate around ear neck, limited jaw opening).
  • Idiopathic facial pain (often bilateral, outside trigeminal territory, pain continuous & milder.)
  • Migraine (aura, severe unilateral, assoc GI upset, photophobia).
  • Temporal arteritis (constant pain, jaw claudication, fever, wt loss, tender non pulsatile temporal arts).

Treatment

  • Standard first line treatment is Carbamazepine (NNT 2.6 v placebo) [Evidence Based Neurology].
  • 2nd line: if carbamazepine not effective, antidepressants are useful in neuropathic pain (NNT <5) [Bandolier 2008].
  • Other drugs including Lamotrigine, Phenytoin, Gabpentin, Oxcarbazine, Topiramate, Baclofen, and Clonazepam.
  • For management of chronic pain please see Neuropathic Pain page in the analgesia section.

Other interventions:

  • Microvascular decompression (surgical).
  • Methods producing a partial trigeminal nerve lesion.
  • Neurectomy, radiofrequency thermal ablation, balloon compression, glycerol injections, and radiosurgery.


Content by Dr Íomhar O' Sullivan 18/12/2003.   Reviewed by Dr ÍOS 16/05/2005, 30/01/2007, 30/01/2008. Last review Dr ÍOS 8/05/15