Trigeminal neuralgia is a neuropathic facial pain condition caused by compression or irritation of the trigeminal nerve, resulting in intense electric shock-like pain. It typically affects those over 50 years old and treatment involves medications initially, with surgical options like microvascular decompression or rhizotomy considered if medications fail to control pain. The document discusses the anatomy, classification, symptoms, diagnosis, differential diagnosis, and treatment approaches for trigeminal neuralgia.

1. TRIGEMINAL NEURALGIA
Presented by
Wita I.Septina
Supervised by
Harmas Yazid Yusuf, drg. SpBM

2. INTRODUCTION
• Trigeminal Neuralgia (TN) is neuropathic facial pain
arising from the trigeminal nerve.
• Incidence 4-5 cases : 100.000
• TN or Tic douloureux occur patients > 50 years.
• Male : Female ratio 2 : 3
• Unilateral (97%). Most affected V2 and V3.
• The pain is intense, usually sharp, electric shocklike
pain in face, lasting periods of seconds to 2 minutes ,

3. ANATOMY TRIGEMINAL NERVE
• Cranial Nerve V
o Sensoric e Portio major
o Motoric Portio minor
o Sensoric + motoric n
Gasseri

4. Fig 1. DistributionTrigeminal nerve

5. CLASSIFICATION
1.Typical Trigeminal Neuralgia
(Tic Douloureux)
• Most common form of TN
• Caused by blood vessels compressing the trigeminal nerve root
enters the brain stem
• Irritation from repeated pulsations t caused hyperactivity of the
trigeminal nerve nucleus p resulting TN pain
• Fig 2

6. (a) (b) (c)
Fig 2. Anatomy Trigeminal nerve and Trigeminal neuralgia

7. CLASSIFICATION
2. Atypical Trigeminal Neuralgia
• Unilateral
• Prominent constant
• Boring or burning pain
• Caused by vascular compression upon a specific part of
trigeminal nerve (portio minor)
• A more severe from or progression of typical TN

8. CLASSIFICATION
3. Pre - Trigeminal Neuralgia
Symptoms : odd sensations of pain or discomfort before the first
attack of TN pain
4. Multiple Sclerosis-Related Trigeminal
Neuralgia
• The symptoms & characteristics identical o
• 2 - 4% patients with TN have multiple sclerosis (MS)
• MS formation of demyelinating plaques within the brain
• First attack of pain y younger patients , bilateral

9. CLASSIFICATION
5. Secondary Trigeminal Neuralgia
• Caused by a lesion (tumor)
• A tumor y compresses or distorts the trigeminal nerve facial
numbness, weakness of chewing muscles, constant pain
• Fig 3.
6. Post-Traumatic Trigeminal Neuralgia
• Develop following cranio-facial trauma, dental trauma, sinus trauma,
destructive procedures (rhizotomies)
• Injury t
cold, start immediately or days to years following injury

10. Fig. 3 MRI--- Tumor compressed trigeminal nerve

11. CLASSIFICATION
7. Failed Trigeminal Neuralgia
Medications, microvascular decompression, and
destructive rhizotomy procedure ineffective in controlling
TN pain

12. ETIOLOGY
1.Blood vessels compression at the trigeminal
nerve root
– Demyelination nerve
– A tumor compresses trigeminal nerve
– Injury to the trigeminal nerve
– Un known

13. Clinical Features
1. Severe paroxysmal pain
– The pain intense, stabbing, electrical shock- like, one
side
– Frequently pain free between attacks.
– Lasting only seconds to two minutes
– Each attack spontaneously or be triggered by specific
light stimulation
– Common triggers include touch, talking, eating, drinking,
chewing, tooth brushing, hair combing and kissing.

14. Fig. 4 Progression of Trigeminal Neuralgia

15. DIAGNOSIS
• Anamnesis
• Clinical examination
• CT scan and MRI
• MRIA

16. Differential Diagnosis
1.Glossopharyngeal neuralgia
– Occipital neuralgia
– Paroxysmal hemicrania syndromes
– Migraine and cluster headaches
– Trigeminal neuropathy

17. TREATMENT
• Medication
• Surgical procedure

18. TREATMENT
Medication
• Carbamazepin (Tegretol)
o Anticonvulsants, Drug of choice for TN, effective dose 600 -1200
mg/ day for 3-4 x/ day
o Maintenance dosage 200 mg/d to prevent recurrences
o Side effect : drowsiness, mental confusion, dizziness,
nystagmus,ataxia
• Oxycarbazepine (Trileptal)
o Side effect : nausea, fatique, tremor
o Dose : 2 x 300mg, maximum dose : 2400-3000 mg/day

19. TREATMENT
• Phenytoin (Dilantin)
o Dose: 300-500mg/day for 3x/day
• Side effect : nystagmus, dysarthria, gingival hyperplasia,
hypertrichosis, allergic skin rash
• Gabapentin (Neurontin)
o Dose : 1200 - 3600mg/d, initial dose ; 3x300mg/d.
o Side effect : somnolen, ataxia, fatique

20. TREATMENT
• Baclophen (Lioresal)
Antispasmodic agents
Initial dose : 2-3 x 5 mg/ day.
Duration of action x
Side effect : nausea, fatique

21. TREATMENT
Surgical Procedure
For patients e medical therapy has failed surgery is a viable and
effective option
• Microvascular decompression
• Nerve Injury/ Destructive Procedure (Rhizotomy)
1. Percutaneus Glycerol Rhizotomy
• Percutaneus Balloon Compression Rhizotomy
• Radiofrequency Rhizotomy
• Stereotactic Radiosurgery (Gamma Knife)
• Microsurgical Rhizotomy

22. TREATMENT
• Microvascular decompression
o non-destructive technique
o Under general anesthesia, incising the skin behind
the ear (Craniotomy)
o Identify an arterial loop compressing the nerve n pad
the vascular structure with Teflon felt
o Complication: CSF leaks, hearing loss, permanent
anesthesia over the face

23. TREATMENT
• Nerve Injury/ DestructiveProcedure
(Rhizotomy)
1. Percutaneus Glycerol Rhizotomy
The surgeon introduces a trocar or needle lateral to the
corner of the mouth into foramen ovale l glycerol–ganglion
Gasseri f nerve injury
2. Percutaneus Ballon Compression Rhizotomy
Under general anestesia – operator insert a balloon
catheter through the the foramen ovale r the region of the
ganglion

24. TREATMENT
3. Radiofrequency Rhizotomy
Intravena sedation h electroda insert to ganglion
electroda to heat thermal injury r to ganglion
4. Strereotactic Radiosurgery (Gamma Knife)
Gamma Knife Radiosurgery g
stereotactic MRI, determined radiation dose to guickly
relief pain without facial sensory loss
5. Microsurgical Ryzotomy

25. CONCLUSION
• Trigeminal Neuralgia (TN) is neuropathic
facial pain arising from the trigeminal
nerve.
• Treatment for TN n
initial therapy if pharmacologic treatment
fails l surgical procedure.