How to diagnose and treat trigeminal neuralgia in a proper way

1. TRIGEMINAL NEURALGIA
(TN)
TIC DOULOUREUX
THE SUICIDE DISEASE
OSAMA ALKHA LIFA

2. Trigeminal Neuralgia
Case summary
A 57 years old female presented with a
complaint of a sudden, sharp, electric
shock-like pain involving left cheek. The
pain started two days back and is initiated
by touching the face or talking. Patient
thinks that it is a dental pain and
requested treatment

3. Trigeminal Neuralgia
Case summary
No dental cause was identified
and a diagnosis of trigeminal
diagnosis was made as a
provisional diagnosis. The
patient was advised to be seen
by a neurologist.
The diagnosis was confirmed and
patient given carbamazepine

4. Trigeminal Nerve Anatomy
5th cranial nerve CNV
Two roots
1- Sensory root with trigeminal
(gasserian, semilunar) ganglion
2- Motor root
Three divisions
1- Ophthalmic V1 sensory
2- Maxillary V2 sensory
3- Mandibular V3 mixed

5. Trigeminal Neuralgia
Clinical presentation
Sharp brief pain
Sudden, sharp, stabbing, electric shock-like,
brief (few seconds to less than two
minutes), intense paroxysms of pain
confined to one or more divisions of the
trigeminal nerve

6. Clinical presentation
Unilateral location
Usually unilateral (96%) with the right side
more affected
V2 and V3 most affected
No neurologic deficit
No dentoalveolar cause found
Local anesthesia of trigger zone temporarily
arrests pain

7. Clinical presentation
Refractory period
There is refractory period during which pain
cannot be reinitiated for a period of time.
At times, a background aching or burning
pain is present

8. Clinical presentation
trigger-zone
Usually a trigger-zone is present where
mechanical stimuli may provoke an attack.
Common cutaneous trigger zones include
the corner of the lips, cheek, ala of the
nose. Intraoral sites include teeth, gingivae
or tongue.

9. Epidemiology
Incidence 3 – 8 : 100,000 / year
Female-to-male ratio 1.6 - 1.74 :1 (3:2)
Occurs above 50 years of age

10. Epidemiology
Pain Distribution in the Various Nerve Branches
in Trigeminal Neuralgia
V1 only 4%
V2 only 17%
V3 only 15%
V2 + V3 32%
V1 + V2 14%
V1 + V3 0.4
V1 + V2 + V3 17%
Rozen 2004

11. Causes of trigeminal neuralgia
Primary trigeminal neuralgia
Vascular compression
Secondary trigeminal neuralgia
Tumors
Multiple sclerosis (MS)

12. Causes of trigeminal neuralgia
Vascular compression
Pressure on the root by a vascular loop
leads to local demyelination
This in turn precipitates hyperactive
discharge of the nerve
The site of demyelination determines the
trigeminal division involved and hence the
clinical presentation

13. Causes of trigeminal neuralgia
Tumors and MS
Paroxysms of pain last longer, pain tends to
be constant, neurologic deficit is often
detected (cutaneous hypoesthesia, loss of
corneal reflex, masticatory muscle
weakness)

14. Diagnosis of trigeminal neuralgia
1- Clinical features
2- MRI:
- Exclude specific pathologies such as
a tumor or multiple sclerosis.
- Sometimes the MRI scan is sensitive
enough to detect blood vessels that
have come in contact with the
trigeminal nerve.

15. Treatment
Medical
1- Anticonvulsants drugs
2- Tricyclic antidepressants drugs
3- Antispastic
Surgical
1- Denervation
2- Microvascular decopression

16. Medical Treatment
Anticonvulsants
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Oxcarbazepine
(Trileptal)
Gabapentin (Neurontin)
Clonazepam (Klonopin)
Divalproex (Depakote)
Pregabalin (Lyrica)
Lamotrigine (Lamictal)
Topiramate (Topamax)
Tiagabine (Gabatril)
Levateracitam (Keppra)
Tricyclic
antidepressants
Amitriptyline (Elavil)
Doxepin (Sinequan)
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Antispastic
Baclofen (lioresal)

17. Medical Treatment
Carbamazepine
Initially it is started with low dose of 100mg once or
twice a day and gradually increasing Up to
1200mg/day or till pain is relieved.
Maintenance dose 400-1200 mg/day for at least 4-6
months before one plans to taper the medications.
It gives an initial relief of pain in about 70 - 90% of
cases.

18. Medical Treatment
Phenytoin
The dose is 300 mg/day and can be
increased up to 600mg/day depending
upon the response and tolerability of the
patients.
It gives an initial relief of pain in about 50 -
60% of cases.

19. Medical Treatment
Baclofen
2nd line drug. Dose 15 - 60 mg/day.
It gives an initial relief of pain in about 65 – 74
% of cases.
Baclofen is used with other anticonvulsants
One warning is there that premature tapering
of baclofen may lead to recurrence of pain and
which may be difficult to control with
medications.

20. Surgical Treatment
1- Microvascular decompression MVD
2- Denervation
- Sectioning of the nerve
- Percutaneous procedures
(radiofrequency lesion(RF), alcohol or
glycerol injection balloon compression,)
- Radiosurgery

21. Surgical Treatment
Microvascular decompression (MVD)
Introduced by Jannetta 1979,
Decompressing by placing alloplastic materials between the
vessels and the roots
Advantages:
Nondestructive spares nerve, Treat cause, may be curative
Rare sensation problems
Disadvantages:
GA and craniotomy required
Risk of serious and lethal complication
Limited to healthy patients

22. Surgical Treatment
Sectioning of the nerve
1- Sensory root (rhizotomy)
2- Peripheral nerve (neurectomy)

23. Surgical Treatment
Radiofrequency
Thermocoagulation Rhizotomy
(RTR)
Thermocoagulation is done by
applying temperature of 60C and
then gradually increases
temperature application until
80C° within 60 second

24. Surgical Treatment
Percutaneous procedures
Advantages:
Safe well tolerated despite age or infirmity
Brief, no hospitalization
Easily repeated if necessary
Disadvantages:
Treat symptoms not cause
Destructive alters facial sensation
Risk of corneal anesthesia
Dysesthetic sequelae could be severe
Increased recurrence with passage of time

25. Surgical Treatment
Radiosurgery
Advantages:
Safe well tolerated despite age or infirmity
Brief, no hospitalization
Easily repeated if necessary
Disadvantages:
Treat symptoms not cause
Delayed therapeutic response
Risk of corneal anesthesia
Increased recurrence with passage of time

26. Surgical Treatment
Balloon compression
This procedure was originally
recommended when other
techniques failed to relieve
trigeminal pain
There is significant risk of
masseter weakness

27. Surgical Treatment
Glycerol rhizolysis
Classic in elderly, infirm
patients and in recurrence
after MVD

28. Surgical Treatment
Gammaknife Radiosurgery (GKRS)
Minimally invasive. It is based on the
principle of using focused radiation beam
to alter axonal function in such a way to
relieve pain. Useful in old and unhealthy
patients.
The effect of GKRS takes 3 weeks to 3
months for pain relief to begin

29. Conclusion
For the the dentist the critical issue is
recognizing TN so that unneeded dental
treatment is avoided.
Unfortunately when the trigger zone is
located in an intraoral site unnecessary
dental treatment is quite common
Peterson
Contemporary Oral and Maxillofacial Surgery
4th edition 2003