Basics and easy concepts of neuralgia with required explainations.

1. SEMINAR ON NEURALGIA
Presented by :
Sharad chand
Pharm D 4rth year

2. Neuralgia
 It is a type of pain disorder.
 Neuralgia is pain that follows the path of a
nerve.
 It is a severe pain disorder of nerve in term of
its distribution due to its irritation or damage.

3. Causes
 Certain drugs
 Chemical irritation
 Diabetes
 Pressure on nerves by nearby structures (for
instance, tumors)
 Swelling and irritation (inflammation)
 Trauma (including surgery)
 Various infections.

4. Symptoms
 Pain, or muscle weakness due to motor nerve
damage
 Increased sensitivity of the skin or numbness
 Pain along the path of a specific nerve

5. Signs and tests
 Abnormal sensation in the skin
 Loss of deep tendon reflexes
 Loss of muscle mass
 Lack of sweating (sweating is controlled by
nerves)
 Tenderness along a nerve,
 Trigger points (areas where even a slight touch
triggers pain)

6. Complications
 Complications of surgery
 Disability caused by pain
 Side effects of medications used to control pain
 Unnecessary dental procedures .

7. classification
 Atypical (trigeminal):
 Post herpetic neuralgia:
 Glossopharyngeal neuralgia:
 Occipital neuralgia:

8. Trigeminal neuralgia
 Trigeminal neuralgia
is severe spastic,
lancinating facial pain
due to a disorder of
the 5th cranial nerve.

9. Pathophysiology
 Trigeminal neuralgia caused by compression of
the trigeminal nerve entry to the brain stem by
aberrant loops of the cerebeller arteries .

10. risk factors
 Multiple sclerosis
 Pressure on the trigeminal nerve from a
swollen blood vessel or tumor

11. Symptoms
PAIN DURING THE
 Brushing teeth
 Chewing
 Drinking
 Eating
 Lightly touching the face
 Shaving

12. Signs and tests
 Blood tests
 MRI of the head
 Trigeminal reflex testing

13. GOALS OF THE THERAPY.
 Reversing or controlling the cause of neuralgia(if
identified)
 Providing pain relief
 Individualizing the treatment

14. Management
 Carbamazepine 1200mg,
Phenytoin,Gabapentin
 Muscle relaxants (baclofen, clonazepam)
 Tricyclic antidepressants :
 (amitriptyline, nortriptyline, or carbamazepine)
 If treatment fail then go for surgical treatment
:
 Inject the alcohol or phenol into peripheral
branch of nerve.

15. Sl
No
Drugs Initial Dose
(mg)
Maintenance
Dose(mg)
Maximum
Daily
Dose(mg)
1 Carbamazepine 100 200 qid 1200
2 Phenytoin 100 100-400 qd/bid 400
3 Lamotrigine 25 qd 25 bid 500
4 Gabapentin 300 qd 300-900 qd/bid 1200-3600
5 Pregabalin 100qd 300 600

16. Adverse effects
Drowsiness, ataxia, dizziness,
blurred vision, diplopia,
headache, rash, dry mouth,
thrombocytopenia

17. TRICYCLIC ANTIDEPRESSANTS
(TCAs)
Sl
No
DRUGS DOSE
(mg)
MAXIMUM
DOSE (mg)
1 Amitriptyline 25 qd 150
2 Nortriptyline 25 qd 125
3 Desipramine 25 qd 150
4 Imipramine 25 qd 150

18. Adverse effects
Sedation, dry mouth, blurred vision,
constipation, weight gain,
orthostatic hypotension, urinary
hesitancy or retention, reduced
gastrointestinal motility

19.  Balloon Compression of Gasserian Ganglion
In this treatment a small balloon catheter is
introduced through the needle into the nerve in the
skull base. With the patient anesthetized the
balloon is briefly inflated to compress the nerve
and then removed.
 Initial pain relief is high: 93% and pain recurrence
similar to radiofrequency treatment, about 20%
over a few years. Numbness in the face,
unfortunately is high (72%). Infection again is a
hazard.

20.  Glycerol Injection
Injection of glycerol into the gasserian
ganglion is a simple and effective treatment.
Using a brief, intravenous anesthetic a needle
is introduced into the nerve in the base of the
skull and a small amount of glycerol injected.
The treatment only takes a few minutes.
Eighty-five percent of patients achieve
immediate pain relief .

21. Post herpetic neuralgia
 Postherpetic neuralgia (PHN) is
a neuralgia caused by the varicella zoster
virus.
 Typically, the neuralgia is confined to
a dermatomic area of the skin and follows an
outbreak of herpes zoster (HZ, commonly
known as shingles) in that same dermatomic
area.

22. HERPES INFECTION.

23. Pathophysiology
 Postherpetic neuralgia is thought to be nerve
damage caused by herpes zoster.
 The damage causes nerves in the
affected dermatomic area of the skin to send
abnormal electrical signals to the brain. These
signals may convey excruciating pain, and may
persist or recur for months, years or until death.

24. Risk
 Site of HZ involvement
 Lower risk - Jaw, neck, sacral, and lumbar
 Moderate risk - Thoracic
 Highest risk - Trigeminal (especially ophthalmic
division), brachial plexus
 Severe prodromal pain (with HZ)
 Severe rash

25. Symptom and Signs:
 Symptoms:
pain that continues for 3 months or more is
defined as PHN.
 Pain is variable from discomfort to very severe and
may be described as burning, stabbing, or
gnawing.
 Signs:
 Sensation may be altered over involved areas, in
the form of either hypersensitivity or decreased
sensation.

26. Management
 Mild case –simple analgesia.
 Moderate to severe case –
 Anti viral agent
 Famciclovir
 Acyclovir
 Valaciclovir


27.  Analgesia locally applied topical agents Aspirin
mixed into an appropriate solvent such
as diethyl ether may reduce pain.
 Lidocaine skin patches.
 Antidepresent agent amitriptyline
 Anticonvulsant agent gabapentin

28. Glossopharyngeal
 Glossopharyngeal neuralgia consists of
recurring attacks of severe pain in the back of
the throat, the area near the tonsils, the back of
the tongue, and part of the ear. The pain is due
to malfunction of the 9th cranial nerve
(glossopharyngeal nerve), which moves the
muscles of the throat and carries information
from the throat, tonsils, and tongue to the brain.

29. Symptoms
 Symptoms include severe pain in areas
connected to the ninth cranial nerve:
 Back of the nose and throat (nasopharynx)
 Back of the tongue
 Ear
 Throat
 Tonsil area
 Voice box (larynx)

30. Cause
 Blood vessels pressing on the
glossopharyngeal nerve
 Growths at the base of the skull pressing on
the glossopharyngeal nerve
 Tumors or infections of the throat and mouth
pressing on the glossopharyngeal nerve

31. Signs and tests
 Blood tests (sugar level) to look for the causes
of nerve damage
 CT scan of the head
 MRI of the head
 X-rays of the head or neck

32. Treatment
 The most effective drugs are antiseizure
medications, such as
 Carbamazepine,
 Gabapentin,
 Phenytoin.
 Some antidepressants, such as
 Amitriptyline
 Nortriptyline,

33.  In severe cases, when pain is difficult to treat,
surgery to take pressure off the
glossopharyngeal nerve may be needed. Or
(rhizotomy).

34. Occipital neuralgia
 Occipital neuralgia, also known as
C2 neuralgia, Arnold's neuralgia, is a medical
condition characterized by chronic pain in the
upper neck, back of the head and behind
the eyes.

35. Causes
 Occipital neuralgia is caused by damage to these
nerves.
 They can be damaged include trauma (usually
concussive),
 Physical stress on the nerve, repetitious neck
contraction,
 Flexion or extension, complications (such
as osteochondroma.
 One cause is vascular compression.

36. Symptom
 The symptom of this condition is
chronic headache.
 The pain is commonly localized in the back of
head and around or over the top of the head,
sometimes up to the eyebrow or behind the
eye.

37. Treatment
 These include local nerve block,
 Peripheral nerve stimulation,
 Steroids
 Rhizotomy,
 Phenol injections,
 Antidepressants such as
Amitriptyline
Nortriptyline,

 Occipital Cryoneurolysis.

38. CONCLUSION.
 Neuralgias are chronic affliction
 Need constant following care
 Not life-threatening disorders
 Chances of recurrence
 Medication adherence
 Anticonvulsants and TCAs
 Duration of treatment.

39. References
 The merck manual of medical information,
second home edition ,page no. 593-594.
 Harrison’s manual of medicine ,17th
edition,page no 1020-1024 ,Mc-Graw hill
publication.
 Harrison’s neurology in clinical medicine, 2nd
edition ,page no 377-383. Mc-Graw hill
publication.

40. Thank you