TRIGEMINAL NEURALGIA
DR. ANGELO SMITH M.D
WELLING HEALTHCARE
PRIVATE LTD
Trigeminal neuralgia
INCIDENCE
 Also called tic douloureax
 Uncommon cranial nerve disorder
 More common in women @ 50-60 years
of age – 3:2...
Trigeminal neuralgia
Causal Factors
 Initiating pathologic events
include:
nerve compression by tortuous
arteries of the posterior fossa
bloo...
Pathophysiology
 Classical (idiopathic) form
 There is no known cause for the, however, studies
point to an underlying v...
Compression of the Trigeminal
Ganglion
 Vascular
 Tortous atherosclerotic branch of the
basilar artery
 Basilar artery ...
Demyelinating Disorder #2
(axonal hyperexcitability)
 Multiple sclerosis (MS) – plaques
at the nerve root entry
 After n...
Demyelinating Disorder #3
(axonal hyperexcitability)
 Post-infectious
Herpes zoster
Tympanomastoiditis
Dental carries ...
Clinical manifestations
 Abrupt onset with excruciating pain!!
 Pain described as burning, knifelike, or
lighting like s...
Clinical manifestations
 Attacks may be brief (2 or 3 minutes)
 Unilateral
 Episodes may be initiated by triggering
mec...
Precipitating stimuli
 Chewing, brushing teeth, hot or
cold blast of air on the face,
washing the face, yawning, or
talki...
Differential Diagnosis:
1. Demyelinating (MS)  Neurology
2. CPA tumors  Neurosurgery
3. Nasopharyngeal and Para nasal
pa...
Diagnostic studies
 Need to rule out other
neurological causes of facial and
cephalic pain.
 CT scan will rule out brain...
General Algorithm
FACIAL PAIN
Clinical Symptomat
ic
Referre
d
Therapeutic Options
 Pharmacologic
Antiepileptic drugs
Anticonvulsant drugs have been used in
the management of pain si...
Antiepileptic Drugs (AED)
 Carbamazepine
 Phenytoin
 Gabapentin
 Pregabalin
 Clonazepam
 Sodium Valproate/Divalproex...
TN Pain
Carbamazepine
+ Baclofen
Carbamazepi
ne
Pregabalin
Carbamazepine
+ Gabapentin
Phenytoin
Phenytoin +
Baclofen
Clona...
Non-Antiepileptic Drugs
 Baclofen
 Tocainide
 Pimozide
 Chloripramine
 Amitriptyline
 Tizanidine
 Proparacaine
Non-pharmacologic: Surgical
 Peripheral Neurectomy
 supraorbital, infraorbital and mental nerves
 Intracranial trigemin...
Trigeminal neuralgia - made easy
Trigeminal neuralgia - made easy
Trigeminal neuralgia - made easy
Trigeminal neuralgia - made easy
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Trigeminal neuralgia - made easy

  1. 1. TRIGEMINAL NEURALGIA DR. ANGELO SMITH M.D WELLING HEALTHCARE PRIVATE LTD
  2. 2. Trigeminal neuralgia
  3. 3. INCIDENCE  Also called tic douloureax  Uncommon cranial nerve disorder  More common in women @ 50-60 years of age – 3:2 ratio.  Trigeminal nerve is 5th cranial nerve (CNV)  And has both motor and sensory branches; mostly maxillary and mandibular branches involved.
  4. 4. Trigeminal neuralgia
  5. 5. Causal Factors  Initiating pathologic events include: nerve compression by tortuous arteries of the posterior fossa blood vessels  demyelinating plaques  herpes virus infection  infection of teeth and jaw
  6. 6. Pathophysiology  Classical (idiopathic) form  There is no known cause for the, however, studies point to an underlying vascular pathology as a cause by irritation over the trigeminal (Gasserian) ganglion.  Age of onset – 52 – 58 yrs  Symptomatic (secondary) form,  There are known common causes affecting the CNV  Compression of the trigeminal ganglion  Demyelinating Disorder (axonal hyper excitability)  Age of onset – 30 – 35 yrs
  7. 7. Compression of the Trigeminal Ganglion  Vascular  Tortous atherosclerotic branch of the basilar artery  Basilar artery aneurysm  Cerebello-Pontine Angle (CPA) Mass  Meningioma  Chordoma  Neurinoma  Metastatic (nasopharyngeal Ca)
  8. 8. Demyelinating Disorder #2 (axonal hyperexcitability)  Multiple sclerosis (MS) – plaques at the nerve root entry  After nerve injury Post-trauma Post-dental procedure Post-mandibular trauma
  9. 9. Demyelinating Disorder #3 (axonal hyperexcitability)  Post-infectious Herpes zoster Tympanomastoiditis Dental carries (micro abscesses and pulp degeneration)  Inflammatory Connective tissue disease (Sjogren’s Disease)
  10. 10. Clinical manifestations  Abrupt onset with excruciating pain!!  Pain described as burning, knifelike, or lighting like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose.  Patient may twitch, grimace, frequent blinking and tearing of eye (tic) may occur.  Affects the face near the nose or mouth (trigger points)
  11. 11. Clinical manifestations  Attacks may be brief (2 or 3 minutes)  Unilateral  Episodes may be initiated by triggering mechanism of light cutaneous stimulation as a specific point (trigger zone) along nerve branches.  With no demonstrable sensory nor motor deficits  Attacks may be restricted to 1 or 2 divisions of the trigeminal nerve  Usually involves the 2nd branch (maxillary) and/or 3rd branch (mandibular) division.
  12. 12. Precipitating stimuli  Chewing, brushing teeth, hot or cold blast of air on the face, washing the face, yawning, or talking.  Patient may eat improperly, neglect hygiene practices, wear cloth over face, withdraw from interaction with others.
  13. 13. Differential Diagnosis: 1. Demyelinating (MS)  Neurology 2. CPA tumors  Neurosurgery 3. Nasopharyngeal and Para nasal pathology  ENT 4. Dental Pathology  Dentistry 5. Herpes zoster  Neurology 6. Classical  Medications  Neurosurgery 7. Unstable angina  Cardiology
  14. 14. Diagnostic studies  Need to rule out other neurological causes of facial and cephalic pain.  CT scan will rule out brain lesions, vascular malformations. LP and MRI will r/o MS.  There is no specific diagnostic test for TN.
  15. 15. General Algorithm FACIAL PAIN Clinical Symptomat ic Referre d
  16. 16. Therapeutic Options  Pharmacologic Antiepileptic drugs Anticonvulsant drugs have been used in the management of pain since the 1960s and the clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning. Non-antiepileptic drugs  Surgical
  17. 17. Antiepileptic Drugs (AED)  Carbamazepine  Phenytoin  Gabapentin  Pregabalin  Clonazepam  Sodium Valproate/Divalproex  Lamotrigine  Oxcarbazepine
  18. 18. TN Pain Carbamazepine + Baclofen Carbamazepi ne Pregabalin Carbamazepine + Gabapentin Phenytoin Phenytoin + Baclofen Clonazepam Sodium Valproate Lamotrigine Oxcarbazepine Surgical Treatment AED +/- Painless for 6 weeks Taper dose in 4 weeks With recurrence
  19. 19. Non-Antiepileptic Drugs  Baclofen  Tocainide  Pimozide  Chloripramine  Amitriptyline  Tizanidine  Proparacaine
  20. 20. Non-pharmacologic: Surgical  Peripheral Neurectomy  supraorbital, infraorbital and mental nerves  Intracranial trigeminal rhizotomy  portio major  Glycerol gasserian gangliolysis  Microvascular decompression  Stereotactic radiosurgery  Radiofrequency rhizotomy

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