Prof Joanna Zakrzewska - Trigeminal neuralgia in MS patients
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This document summarizes a presentation on trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). Some key points: - TN occurs in 2-4% of MS patients, who may experience more constant, bilateral pain compared to other TN patients. - Diagnosis involves investigating potential causes like neurovascular compression through MRI and ruling out other conditions. - Treatment includes carbamazepine, oxcarbazepine and other medications, as well as ablative surgical procedures for refractory cases. - More research is needed on the prevalence and management of TN specifically in MS patients compared to other populations.
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Prof Joanna Zakrzewska - Trigeminal neuralgia in MS patients
- 1. Trigeminal neuralgia in MS patients Prof Joanna Zakrzewska Facial pain unit, Eastman Dental Hospital MS Trust Annual Conference 2015
- 2. Aims and Objectives Trigeminal neuralgia 2. Diagnosis Investigations 4. Medical management Surgical management 3. Impact 1. Epidemiology Types of facial pain 5. Research questions
- 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. Drangsholt et al 2001 What are other causes of unilateral episodic facial pain?
- 5. Chronic continuous pain Unilateral continuous orofacial pain Yes No Yes No • Post herpetic neuralgia • Post traumatic trigeminal pain • Anesthesia dolorosa • Persistent dentoalveolar pain • Referred pain • Temporomandibular disorders** • Persistent orofacial muscle pain ** Unilateral episodic orofacial pain Yes No • Trigeminal neuralgia classical (type 1) • Trigeminal neuralgia symptomatic • Trigeminal neuralgia + concomitant pain ( type 2) • Glossopharyngeal neuralgia • Tension type headache • Medication overuse headache • Post stroke pain • Giant cell arteritis * Cancer pain Burning mouth syndrome Chronic migraine • Trigeminal autonomic cephalagias • Episodic migraine * Persistent idiopathic facial pain Zakrzewska BJA 2013
- 6. 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. Misery by Rosa Sepple
- 7. Character of TN pain Sharp Electric shock like Stabbing Fearful Unbearable
- 8. © Zakrzewska Duration paroxysmal pain of abrupt onset and termination refractory intervals no background pain memorable first attack
- 9. © Zakrzewska Temporal features Classical TN TN – Type 2, concomitant pain
- 12. © Zakrzewska Provoking factors Light touch provoked# Eating/brushing teeth Washing /shaving Cold wind Evoked vs spontaneous
- 13. 60 sec 45 sec 30 sec 15 sec Attack of TN @ Prof Sharav
- 14. Associated features Unable to maintain good oral hygiene Loneliness Depression
- 15. Effects of TN I try so hard to laugh and joke, so I do not cry. I am sick of crying, it is time to laugh and try to find some enjoyment in my life again People tell me that I look good and I must be feeling pretty good. They tell me many people are in worse pain than I am
- 16. Effect of TN I feel that I am a burden to my family, very, very frustrated at lack of ability to do things and go places. Constantly cancelling attendance at events ... very poor quality of life now – maddening My whole life was falling apart. Everything was falling apart in our house, my job and there was nothing I could do about the pain.
- 17. Fear ©Eastman
- 18. Tolle et al Pain Practice 2006
- 19. The Patient’s Journey Through Trigeminal Neuralgia Zakrzewska Padfield May 2014
- 20. Trigeminal Neuralgia Same in MS patients? Maarjberg et al 2014; Limonadi et al 2006, Obermann et al 2007
- 22. TG MS plaque
- 25. Zakrzewska JM, Linskey M 2014
- 26. Drugs used in TN baclofencarbamazepine valproate lamotrigineepanutin clonazepam
- 27. Drugs used in TN gabapentin pregabalinoxcarbazepine sumatriptan leviteracetam Dextromethorphan Topiramate Botox
- 28. Carbamazepine 3 RCT studies (total 280 patients) Number Needed to Treat 2 for >50% pain relief Maximum 2.4 g / day Usual dose 200-1,200 mg Number needed to harm 4 Multiple drug interactions
- 29. Carbamazepine adverse events osteoporosis © Zakrzewska
- 30. Oxcarbazepine Starting 300 mg bd Dose range 600-1,200 mg /day Maximum 2,400 mg/day Hyponatraemia higher doses Few drug interactions
- 31. Adverse effects of AEDs using AEP 161 patients
- 32. Women more sensitive to carbamazepine and oxcarbazepine Besi et al J Headache Pain 2015
- 33. Pain diaries Drug dosages Change of pain
- 34. AAN/ EFNS Guideline Do they apply to MS patients?
- 35. Insufficient evidence to say when surgery should be offered Patients should be given details of all surgical procedures
- 36. Systematic review surgery 3 studies 2 radiofrequency thermocoagulation comparing techniques 1 stereotactic surgery comparing dosages Cochrane Database of Systematic Reviews 2011, Issue 9 Grading
- 37. Gasserian Ganglion procedures Ablative/ destructive Radiofrequency rhizotomy Glycerol rhizotomy Balloon compression
- 38. Stereotactic radiosurgery Gamma knife, Cyberknife Radiation doses of 90- 70Gy Non invasive Destructive procedure
- 39. Microvascular decompression Non destructive Posterior fossa Zakrzewska Coakham Current Neurol 2012
- 40. AAN/EFNS guidelines Does this apply to MS patients?
- 41. 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
- 42. Support groups US , UK, Australia , Canada Web sites : http://www.tna-support.org/ http://www.tna.org.uk/ © Zakrzewska
- 44. Microvascular decompression MS Drug therapy Neurovascular compression Drug therapy Tumours etc Idiopathic TN MRI Blood tests Symptomatic TN Ablative procedures Gasserian ganglion Gamma knife Trigeminal neuralgia Primary care Carbamazepine Initial good control but now failing Refer pain clinic Neurology headache Neurosurgery Poor quality of life Carbamazepine Oxcarbazepine Lamotrigine Baclofen Pregablin Gabapetin Joint neurosurgery clinic Psychology © Zakrzewska
- 45. TN Review BMJ 2014 Zakrzewska JM , Linskey ME 2015 BMJ Clinical Evidence Podcast on Trigeminal neuralgia available at http://www.bmj.com/content/350/bmj.h1238
- 49. Educational material http://www.efic.org/ Year against orofacial pain 2013-4
- 50. Rosa Sepple http://www.rosasepple.com/index.htm The Mall Solo exhibition 2015
- 51. Unresolved questions • How many patients with MS have facial pain? • How many patients with MS have TN and its variants? • How do they respond to drug therapy? • Should MS patients have destructive procedures? • Do MS patients need more support? Interested in helping? J.Zakrzewska @ucl.ac.uk TNA Jillie Abbott admin@tna.org.uk