trigeminal neuralgia is a facial pain syndrome in distribution of trigeminal nerve...

1. TRIGEMINAL NEURALGIA
- Dr.Akif A.B

2. Trigeminal neuralgia (TN) is a facial pain syndrome in the
distribution of ≥1 divisions of the trigeminal nerve.
Definition
Divisions of the trigeminal nerve
V1 - Ophthalmic division
V2 - Maxillary division
V3 - Mandibular division

3. Etiology
1) Compression : Trigeminal nerve root compression by aberrant
vascular loop (mostly superior cerebellar artery)
2) Demyelination : Trigeminal neuralgia is 20times more common in
patient with multiple sclerosis
3) Other brainstem causes : Amyloid and brainstem infarcts

4. Risk factors
1) Advancing age
2) Multiple sclerosis
3) Females > males

5. Unilateral paroxysms of facial pain lasting seconds to minutes in a
distribution along ≥1 divisions of the trigeminal nerve.
Triggers such as tooth brushing, eating, cold, and touch are common.
Most patients are asymptomatic between episodes and
No neurological deficit
history of prior oropharyngeal or facial trauma
prior diagnoses (such as prior herpetic outbreak)
History of rash or facial droop that may direct diagnosis away from TN
History

6. Physical examination
-Normal Physical and neurological examination
-Neurological deficit indicates someother cause
examination of dentition and oropharynx, assessment of TMJ
function, skin examination, palpation of temporal arteries, and full
neurological examination with particular focus
on facial sensory examination to be done to rule out other causes

7. Investigations
-No specific investigation
-Intraoral X-ray to rule out other causes
-MRI Brain to rule out Intracranial causes

8. Differential Diagnosis
Migraine and Cluster Headache
-Pain is deep seated and steady whereas in TN pain is superficial and
stabbing type
-Rarely cluster headache is associated with Trigeminal neuralgia known as
Cluster Tic.

9. Differential Diagnosis
Temporal arteritis
- Pain is superficial but is associated with myalgias, systemic
symptoms and Raised ESR

10. Differential Diagnosis
-Trigeminal neuralgia in young
-Bilateral Trigeminal Neuralgia
Multiple sclerosis should be suspected
Multiple Sclerosis

11. Differential Diagnosis
Dental injury or mandibular osteomyelitis
- Can be ruled out by Intra-Oral X-Ray

12. Diagnostic Criteria
1. Distribution along ≥1 divisions of the trigeminal nerve
2. Pain is described as sudden, intense, sharp, superficial, stabbing, or
burning in quality
3. Severe intensity
4. Attacks are precipitated by known triggers
5. Patient is asymptomatic between episodes
6. Lack of neurological deficit
7. Attacks are stereotyped in a given patient
8. Other causes of facial pain have been excluded by history/physical
examination/studies.
4 out of 8

13. TREATMENT
Medical therapy Surgical
Anticonvulsants

14. Newly diagnosed
Trigeminal Neuralgia
Carbamazepine
Oxcarbazapine
Lamotrigine
Anti convulsants
-Side effects : Dizziness, Imbalance, agranulocytosis & Steven Johnson Sx
-Carbamazepine : 200mg/d in 1-2 divided doses initially
usual maintenance dose is 400-1200mg/d in 1-2 divided
dose.
oxcarbazepine: 300 mg/day orally initially, usual maintenance dose is 600-
1200 mg/day, maximum 1200 mg/day given in 2 divided
doses

15. Secondary options
» Topiramate: 12.5 to 25 mg/day orally initially,
increase gradually according to response,
maximum 200 mg/day
Tertiary options
» Gabapentin: 300 mg orally once daily
initially, usual maintenance dose is 300-1800
mg/day, maximum 1800 mg/day given in 3
divided doses
Newly diagnosed
Trigeminal Neuralgia

16. Anti-convulsant Unresponsive
Trigeminal Neuralgia
Baclofen
15 mg/day orally initially given in 3 divided doses, increase according to
response, maximum 80 mg/day

17. Medicine Unresponsive
Trigeminal Neuralgia
-Microvascular decompression
-Neurostimulation

18. STEPHEN
JOHNSON
SYNDROME