Trigeminal neuralgia: Difference between revisions
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==Clinical | ==Background== | ||
*Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds | [[File:Gray778.png|thumb|Trigeminal nerve anatomy.]] | ||
*Normal neuro exam | [[File:Gray784.png|thumb|Dermatome distribution of the trigeminal nerve: V1 (green), V2 (red), and V3 (yellow).]] | ||
*Also known as tic doulourex | |||
==Clinical Features== | |||
*Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds | |||
*Normal neuro exam | |||
*No pain between paroxysms | *No pain between paroxysms | ||
*Variant with headache | |||
*More common in Middle aged women | |||
*Frequently triggered by minimal stimuli (e.g. light touch, gentle breeze) | |||
==Differential Diagnosis== | |||
{{Headache DDX}} | |||
{{Facial paralysis}} | |||
==Evaluation== | |||
*Sensory loss, bilateral involvement, and younger age (<40) are associated with a higher risk of secondary TN, but their absence does not rule out secondary TN | |||
*Consider [[head CT|CT]]/[[brain MRI|MRI]] in these patients to rule out structural etiology | |||
*<5% of patients have V1 distribution, examine carefully for [[zoster]] in these patients | |||
==Management== | |||
===[[Carbamazepine]]=== | |||
*First-line agent with 75% success rate initially | |||
*Proposed Mechanism: Decreases the response of neurons to peripheral stimulation | |||
*Started at 100mg one to two times per day | |||
*Increase by 100-200mg every 3 days | |||
*Usual maintenance dose is 400-800mg (rare >1500mg) | |||
*Metabolized by liver (cytochrome P450) | |||
**LFTs monitored on outpatient basis | |||
*Pain relief occurs within several hours to days (94% within 48 hours) | |||
*Target serum concentration is 24-43 μmol/L | |||
**If unsuccessful, [[phenytoin]] 200-400mg/day is used in combination | |||
===Other agents=== | |||
*[[Baclofen]], [[clonazepam]], [[valproic acid]], [[lamotrigine]], [[gabapentin]], [[oxcarbazepine]], [[topiramate]] | |||
===Surgery=== | |||
*Posterior fossa microvascular decompressive surgery | |||
**Approximately 50% of patients will require surgery | |||
*Successful in 70% of patients | |||
== | ==Disposition== | ||
* | *Typically outpatient | ||
== | ==See Also== | ||
*[[Headache]] | |||
==References== | |||
*J Pain Symptom Manage 2001; 21(6):506-510. | |||
[[Category: | [[Category:Neurology]] | ||
Latest revision as of 11:31, 7 August 2022
Background
- Also known as tic doulourex
Clinical Features
- Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds
- Normal neuro exam
- No pain between paroxysms
- Variant with headache
- More common in Middle aged women
- Frequently triggered by minimal stimuli (e.g. light touch, gentle breeze)
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Mild traumatic brain injury
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Facial paralysis
- Bell's palsy
- CVA
- Trigeminal neuralgia
- Tick paralysis
- Herpes zoster oticus (Ramsay Hunt syndrome)
- CNS tumor
- Acoustic neuroma or other cerebellopontine angle lesions
- Meningioma
- Cerebellar pontine angle
- Facial nerve schwannoma
- Parotid
- Sarcoma
- Anesthesia nerve blocks
- Cerebral Aneurysms (vertebral, basilar, or carotid)
Evaluation
- Sensory loss, bilateral involvement, and younger age (<40) are associated with a higher risk of secondary TN, but their absence does not rule out secondary TN
- Consider CT/MRI in these patients to rule out structural etiology
- <5% of patients have V1 distribution, examine carefully for zoster in these patients
Management
Carbamazepine
- First-line agent with 75% success rate initially
- Proposed Mechanism: Decreases the response of neurons to peripheral stimulation
- Started at 100mg one to two times per day
- Increase by 100-200mg every 3 days
- Usual maintenance dose is 400-800mg (rare >1500mg)
- Metabolized by liver (cytochrome P450)
- LFTs monitored on outpatient basis
- Pain relief occurs within several hours to days (94% within 48 hours)
- Target serum concentration is 24-43 μmol/L
- If unsuccessful, phenytoin 200-400mg/day is used in combination
Other agents
Surgery
- Posterior fossa microvascular decompressive surgery
- Approximately 50% of patients will require surgery
- Successful in 70% of patients
Disposition
- Typically outpatient
See Also
References
- J Pain Symptom Manage 2001; 21(6):506-510.