This presentation by Professor Joanna Zakrzewska, Head of facial pain unit at Eastman Dental Hospital, looks at trigeminal neuralgia in MS and how it's diagnosed and managed.
It was presented at the MS Trust Annual Conference in November 2014.
2. Aims and Objectives
Differential diagnosis
Trigeminal neuralgia
Diagnosis
Investigations
Medical management
Surgical management
Epidemiology
Patho-physiology
3. Epidemiology TN
Incidence : 4.5 / 100,000
Prevalence : 0.001% - 0.3%
Peak incidence : 50-60 years
Multiple sclerosis (2- 4 % of TN
patients)
Hypertension
Stroke
Zakrzewska JM, Hamlyn PJ. In Epidemiology of
Pain. IASP, 1999
Mueller D et al Cephalagia 2011
Pan et al Cephalagia 2011
4. Changing epidemiology of TN?
Incidence
per 100,000
PY
Hall et al
2006
Dieleman
2008
Koopman et
al 2009
Number 8,268
322 118
Incidence 26.8
28.9 12.6
5. What are other causes of
unilateral episodic facial pain?
18. The Story of Pain
curiosity to ask “tell me about yourself”
patience to wait for the answer
Platt et al 2001
19. Stories
• patients tell stories to become who they are
• patient stories are addressed to someone
• the clinician must listen
• the quality of attention is important and
you " have to be caught up” – it is an act of
surrender
20. What are the features of
trigeminal neuralgia?
Misery by Rosa Sepple
21. Character of TN pain
The character of trigeminal neuralgia is very
distinctive and pts will use words such electric
shock, lightening – implies speed as well as severity
27. Trigeminal Neuralgia –IASP
“ a sudden, usually unilateral,
severe, brief, stabbing, recurrent
pain in the distribution of one or
more branches of the fifth cranial
nerve”.
29. Associated features
Loneliness – isolation – how can
you go to social activities when
you cannot eat,
how can you be intimate when
you cannot bear your face to be
touched
How do you get across the
message that despite looking
normal you have one of the most
suicide pain
Depression is common
Fear of a returning attack is
always with the patients and
psychologist will tell us that this
drives further pain
58. Novel Sodium Channel Blocker
CNV1014802 June 2014
• Treatment failure rate
33% CNV1014802 vs 65% placebo
• Decrease in pain severity
55% CNV1014802 vs 18% placebo
• Average reduction in number of paroxysms
60% CNV1014802 vs 12% placebo
59. Medications
There is a medicine
you can take
But it’s not the cure
It may make your
drowsy
It may make you sick
There are more pills
to take
And there’s no
miracle fix
72. How 302 patients with MS and TN
compare with 7982 TN only patients ?
Same age and demographics
More constant, bilateral pain
Use wider range of drugs
Undergo more ablative surgery
73. Why are there few TN Drug Trials ?
Diagnosis strictly clinical
Condition relatively rare
Medications may interfere with other drugs
Medications may take time to work
Spontaneous remission common
Side-effects may take time to appear
Pain very severe: justify using placebo