Trigeminal Neuralgia is a condition that occurs on the trigeminal nerve which is the 5th cranial nerve. The patient experiences a paroxysmal, sharp pain which may arise by certain stimuli. These involve touching a certain area, shaving, smiling, etc.

1. TRIGEMINAL
NEURALGIA
BY:-
DR.VARUN KAPOOR
B.D.S.

2. 1. DEFINITION
2. TRIGEMINAL NERVE
3. ETIOLOGY
4. CLINICAL FEATURES
5. PRETRIGEMINAL NEURALGIA
6. POSTHERPETIC NEURALGIA
7. TRIGGER ZONES
8. DIFFERENTIAL DIAGNOSIS
9. LABORATORY FINDINGS
10. TREATMENT

3. DEFINITION
Trigeminal neuralgia is a disease of the
trigeminal nerve that causes sharp, stabbing
pain in the cheek, lips, gums or chin on one
side of the neck.

6. TRIGEMINAL NERVE
Trigeminal nerve is the fifth and the largest cranial
nerve.
Supplies sensation to the face, mucous membranes
and other structures of the head and certain motor
functions such as biting and chewing.
Distributed into 3 major branches:
1. Ophthalmic
2. Maxillary
3. Mandibular

8. The trigeminal nerve
originates from 3
nuclei:-
1. mesencephalic
nucleus
2. main sensory
nucleus
3. spinal nucleus
it exits through mid
pons through
trigeminal ganglion
and divides into 3
main branches:-
1. ophthalmic
2. maxillary
3. mandibular

9. FACTORS RESPONSIBLE FOR
TRIGEMINALNEURALGIA

10. ETIOLOGY
Trigeminal neuralgia is most commonly caused by:-
• The compression of the trigeminal nerve roots by
the blood vessels {superior cerebellar artery or
tortuous vein, increased vascular thickness and
tortuousity}.
• Unsuccessful dental work e.g.: root canal
treatment, faulty restorations, ill fitting dentures.
• Pathology leading to demyelination also makes
the nerve hyper excitable.
• Auto immune diseases like multiple sclerosis.

11. • Proximity of the teeth to the site of the pain
suggested long ago that teeth might be the
source of difficulty.
• When extraction of countless teeth in an effort to
cure the disease failed, the conclusion was finally
made that trigeminal neuralgia is not of dental
origin.
• Periodontal disease and traumatogenic occlusion
have also been suggested as the cause.
• Infrequent dental fillings in adjacent teeth of
different metals may trigger the attack
(galvanism).

13. CLINICAL FEATURES
• The patient experiences an
excruciating paroxsysmal pain
• The pain lasts for a few seconds to a few minutes.
• It is so severe that the patient flinch and clutches
his fingers in fear of the dreaded pain.
• Hence the french term for the condition 'tic
douloureux'.
• It has a sudden onset and tends to persist for weeks
or months.

14. • The pain may be precipitated by
touching the trigger zones or by
chewing, smiling, etc.
• The periods of remission, gradually
become shorter, until the patient is in
continous pain and may become
suicidal.
• Remission is spontaneous and long
lasting, but recurs.
• Unfortunately the time of the seizure
cannot be predicted.

15. PRETRIGEMINAL NEURALGIA
• The dull pain in the early stages has been termed
as pre trigeminal neuralgia.
• The pain is often described as dull, aching or a
sharp toothache.

16. POSTHERPETIC NEURALGIA
• A condition similar to trigeminal neuralgia which
occurs after attack of herpes zoster on the fifth
cranial nerve is termed as post herpetic neuralgia.
• The pain usually involves the ophthalmic division of
the trigeminal nerve, and commonly regresses
between two three weeks.
• It may persist in older patients.

17. SYNONYMS
 Tic Douloureux – Nicholas Andre
 Fothergill’s disease – John Fothergill

18. Affected: Older > Younger

19. Females > Males
3:2
>
Female Male

20. TRIGGER ZONES
• Border of the lips .
• Ala of the nose.
• Cheeks.
• Around the eyes.
• Every patient manifests only one trigger zone.
• The patient learns to avoid touching the trigger area and
usually goes unwashed or unshaven.
• Any portion of the face may be involved in it depending
on which branch of the nerve is affected.
• Maxillary and mandibular branches are more
commonly affected.
• In some cases both the branches may be affected in it.

22. PROGRESSION OF TRIGEMINAL
NEURALGIA OVER TIME
Early in the disease
course
Later in the disease
course
Periods of
Exacerbation
Periods of Remission
As the disease progresses, the
periods of exacerbation are
increased and the periods of
remission are decreased.
Finally the patient is in continous
pain as there is no remission.

23. DIFFERENTIAL DIAGNOSIS
• Pain arises from the jaws and teeth
• Sinusitis
• Migraine
• Cluster Headache
• Trigeminal Neuropathy
• Multiple Sclerosis
Pain is deep seated and
steady
SINUSITIS

24. Name of disease Identifying features
1. Sinusitis Headache, fever, sneezing, post nasal
drip, discomfort in cheeks and
forehead
2. Migraine Euphoria, neck stiffness, difficulty in
speaking, weakness, nausea, blurred
vision,light headedness.
3. Cluster headache Unilateral pain in bouts, eye watering,
drooping eyelid, facial swelling,
restlessness, photo phobia,
phonophobia.
4.Trigeminal neuropathy Loss of sensation over the chin,
weakness of the jaw, paresthesias.
5. Multiple sclerosis Double vision, blindness in one eye,
muscle weakness, trouble with
sensation.

25. INVESTIGATION
In typicalTrigeminal neuralgia, imaging is not of
much use but is helpful in diagnosing multiple
sclerosis, vascular lesions and aneurysms to avoid a
lesion or an aberrant vessel compression on
trigeminal nerve roots.

26. TREATMENT
• Carbamazepine - It is effective in 50%-75%
of the cases. Started as 100mg daily and
escalated by 100 mg daily up to 1200 mg till
the pain subsides.
• Lamotrigene - 400 mg daily.
• Phenetoin - 300 - 400 mg daily
• Beclophen - 5-10 mgT.D.S.

27. • Alcohol injection - it is made into the
gasserian ganglion. Relief from pain
may last six months to two years
following which the sensation usually
returns and the pain with it.
• Repeated injections are necessary and
are made with increasing difficulty due
to fibrosis around the nerve.

28. • Phenol injection - 7.5% phenol with myodil
injected into the ganglia under X-ray
control relieves the pain without loss of
sensation.
• Hot water injection-.Injection of hot
boiling water in the gasserian ganglion has
been found beneficial in causing respite
from pain.

29. SURGICAL INTERVENTION
• Alternatively the vascular compression of the
trigeminal nerve can be relieved by a small
posterior craniotomy.
• This approach is usually favoured in youger
patients in whom other injection treatments
may have to be repeated and become less
effective.