Trigeminal neuralgia, facial pain in MS
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This presentation by Professor Joanna Zakrzewska, Head of facial pain unit at Eastman Dental Hospital, looks at trigeminal neuralgia in MS and how it's diagnosed and managed. It was presented at the MS Trust Annual Conference in November 2014.
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Trigeminal neuralgia, facial pain in MS
- 1. Trigeminal neuralgia, facial pain in MS Prof Joanna Zakrzewska Head of facial pain unit Eastman Dental Hospital
- 2. Aims and Objectives Differential diagnosis Trigeminal neuralgia Diagnosis Investigations Medical management Surgical management Epidemiology Patho-physiology
- 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. Changing epidemiology of TN? Incidence per 100,000 PY Hall et al 2006 Dieleman 2008 Koopman et al 2009 Number 8,268 322 118 Incidence 26.8 28.9 12.6
- 5. What are other causes of unilateral episodic facial pain?
- 6. Drangsholt et al 2001
- 7. Dental causes of pain
- 8. Dental Pain – acute/ chronic
- 9. Chronic continuous pain Yes No Unilateral continuous orofacial pain 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
- 10. Temporomandibular Disorders musculoskeletal © Zakrzewska
- 11. TMD © Zakrzewska
- 12. Education- explanation © Zakrzewska
- 13. Education vs splint Michelotti JADA 2012;143:47-53 © Zakrzewska
- 14. TMD management Reassurance, education, relaxation, behaviour changes, intermittent NSAID Physiotherapy/ acupuncture, pain coping strategies, reinforce self care, address psychological distress Tricyclic antidepressants, cognitive behaviour therapy, reinforce self care © Zakrzewska
- 15. Why is the right diagnosis important? • Epidemiological studies • Genetic studies • Recruiting into clinical trials • Appropriate managements and referrals • Variants may involve different mechanisms © Zakrzewska
- 16. Who makes the diagnosis? HCP making diagnosis TN 5287 ATN 189 OFP 857 General medical practitioner % 36 36 18 Neurologist % 29 30 17 Dentist % 20 15 10 Other specialists % 15 19 55
- 17. Listen to your patient he is telling you the diagnosis
- 18. The Story of Pain curiosity to ask “tell me about yourself” patience to wait for the answer Platt et al 2001
- 19. Stories • patients tell stories to become who they are • patient stories are addressed to someone • the clinician must listen • the quality of attention is important and you " have to be caught up” – it is an act of surrender
- 20. What are the features of trigeminal neuralgia? Misery by Rosa Sepple
- 21. Character of TN pain The character of trigeminal neuralgia is very distinctive and pts will use words such electric shock, lightening – implies speed as well as severity
- 22. © Zakrzewska Duration paroxysmal pain of abrupt onset and termination refractory intervals no background pain memorable first attack
- 23. Temporal features Classical TN TN – Type 2, concomitant pain © Zakrzewska Refractory period
- 25. Site and Radiation Rare
- 26. Provoking factors © Zakrzewska R Conelly Evoked vs spontaneous
- 27. 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”.
- 28. How does TN affect quality of life ? © Zakrzewska © R. Sepple
- 29. Associated features Loneliness – isolation – how can you go to social activities when you cannot eat, how can you be intimate when you cannot bear your face to be touched How do you get across the message that despite looking normal you have one of the most suicide pain Depression is common Fear of a returning attack is always with the patients and psychologist will tell us that this drives further pain
- 30. Fear ©Eastman
- 31. Tolle et al Pain Practice 2006
- 32. The Patient’s Journey Through Trigeminal Neuralgia Zakrzewska Padfield May 2014
- 33. Trigeminal Neuralgia Limonadi et al 2006, Obermann et al 2007
- 34. What is the diagnosis of this patient ?
- 35. Symptomatic TN Trigeminal nerve Tumour © Zakrzewska
- 36. TG MS plaque
- 37. vessel nerve Neurovascular compression
- 39. Nerve Structure © Zakrzewska
- 40. Root entry zone, change in nerve structure
- 42. Love and Coakham, Brain 2001: 124, 2347 – 2360
- 43. Management
- 44. Outcomes % pain Therapy relief Decreased intensity frequency Character of pain Provoking factors Side effects Beliefs concerns Objective measures Health utilisation © Zakrzewska
- 46. Systematic reviews guidelines www.aan.com
- 48. Which have been evaluated in Randomised controlled trials - RCTs? carbamazepine baclofen clonazepam epanutin valproate lamotrigine
- 49. Which have been evaluated in RCTs? gabapentin oxcarbazepine pregabalin sumatriptan leviteracetam Dextromethorphan Topiramate Botox
- 50. Carbamazepine 3 RCT studies (total 160 patients) NNT 1.7 for >50% pain relief Maximum 2.4 g / day Usual dose 200-1,200 mg NNH 2.6 Multiple drug interactions
- 51. Carbamazepine adverse events osteoporosis © Zakrzewska
- 52. Oxcarbazepine Starting 300 mg bd Dose range 600-1,200 mg /day Maximum 2,400 mg/day Hyponatraemia higher doses Few drug interactions
- 53. Side effects to anticonvulsants
- 54. Acute management Fosphenytoin infusion Sumatriptan 3mg sc 24 patients in RCT 12/24 improved for mean 8 hours Lidocaine Injection Intranasal IV Cheshire Fosphenytoin J Pain Sympt 2001 Kania Sumatriptan Head 2006 Han Lidocaine Clin Prac 2008, Kania Br J Aneasth 2006
- 55. Results of RCTs in TN carbamazepine oxcarbazepine lamotrigine baclofen gabapentin + LA pimozide = tizanidine ? tocainide dextromethorphan ? topiramate ?
- 57. New drug for TN
- 58. Novel Sodium Channel Blocker CNV1014802 June 2014 • Treatment failure rate 33% CNV1014802 vs 65% placebo • Decrease in pain severity 55% CNV1014802 vs 18% placebo • Average reduction in number of paroxysms 60% CNV1014802 vs 12% placebo
- 59. Medications There is a medicine you can take But it’s not the cure It may make your drowsy It may make you sick There are more pills to take And there’s no miracle fix
- 62. Insufficient evidence to say when surgery should be offered Patients should be given details of all surgical procedures
- 63. Systematic review surgery Cochrane Database of Systematic Reviews 2011, Issue 9 3 studies 2 radiofrequency thermocoagulation comparing techniques 1 stereotactic surgery comparing dosages Grading
- 64. Gasserian Ganglion procedures Radiofrequency rhizotomy Glycerol rhizotomy Balloon compression
- 65. Microvascular decompression Partial sensory rhizotomy Posterior fossa Zakrzewska Coakham Current Neurol 2012
- 66. Posterior fossa Trigeminal nerve compressed by superior cerebellar artery © Prof H Coakham
- 67. Gamma knife Radiation doses of 90- 70Gy Non invasive ablative procedure
- 68. Complete pain relief after surgery 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 4 5 years % probability radiofrequency thermocoagulation percutaneous glycerol rhizotomy microvascular decompression gamma knife © Zakrzewska
- 69. Complications Mortality 0.2 - 0.5 % for MVD data from 14 studies in 2785 patients © Zakrzewska
- 70. Complications Peripheral ganglion lesions © Zakrzewska
- 72. 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
- 73. Why are there few TN Drug Trials ? Diagnosis strictly clinical Condition relatively rare Medications may interfere with other drugs Medications may take time to work Spontaneous remission common Side-effects may take time to appear Pain very severe: justify using placebo
- 75. Patient Information © Zakrzewska
- 76. Support groups US , UK, Australia , Canada Web sites : http://www.tna-support.org/ http://www.tna.org.uk/ © Zakrzewska
- 78. Drug therapy Microvascular decompression MS Drug therapy Neurovascular compression 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 Carbamazepine Oxcarbazepine Lamotrigine Baclofen Pregablin Gabapetin Poor quality of life Joint neurosurgery clinic Psychology © Zakrzewska
- 79. Choice, Option, Decision http://www.advancingqualityalliance.nhs.uk/SDM
- 80. References / further reading
- 81. TN Review BMJ 2014
- 85. TMD & trigeminal neuralgia http://cks.nice.org.uk/trigeminal-neuralgia http://cks.nice.org.uk/tmj-disorders
- 86. Educational material http://www.efic.org/ Year against orofacial pain
- 87. Summary • Epidemiology provides clues to aetiology • Differential diagnosis • Important diagnostic features of TN • Causes • Investigations • Management • References @ R.Sepple
- 88. Thank you Face to face Rosa Sepple