Trigeminal neuralgia: Difference between revisions
(Text replacement - "<" to "<") |
|||
(10 intermediate revisions by 5 users not shown) | |||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
[[File:Gray778.png|thumb|Trigeminal nerve anatomy.]] | |||
[[File:Gray784.png|thumb|Dermatome distribution of the trigeminal nerve: V1 (green), V2 (red), and V3 (yellow).]] | |||
*Also known as tic doulourex | |||
==Clinical Features== | ==Clinical Features== | ||
Line 7: | Line 10: | ||
*Variant with headache | *Variant with headache | ||
*More common in Middle aged women | *More common in Middle aged women | ||
*Frequently triggered by minimal stimuli (e.g. light touch, gentle breeze) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Headache DDX}} | {{Headache DDX}} | ||
{{Facial paralysis}} | |||
==Evaluation== | ==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 | *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 | *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 | *<5% of patients have V1 distribution, examine carefully for [[zoster]] in these patients | ||
==Management== | ==Management== | ||
===[[Carbamazepine]]=== | ===[[Carbamazepine]]=== | ||
Line 28: | Line 29: | ||
*Increase by 100-200mg every 3 days | *Increase by 100-200mg every 3 days | ||
*Usual maintenance dose is 400-800mg (rare >1500mg) | *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) | *Pain relief occurs within several hours to days (94% within 48 hours) | ||
*Target serum concentration is 24-43 μmol/L | *Target serum concentration is 24-43 μmol/L | ||
Line 33: | Line 36: | ||
===Other agents=== | ===Other agents=== | ||
*[[Baclofen]], clonazepam, [[valproic acid]], [[lamotrigine]], [[gabapentin]], | *[[Baclofen]], [[clonazepam]], [[valproic acid]], [[lamotrigine]], [[gabapentin]], [[oxcarbazepine]], [[topiramate]] | ||
===Surgery=== | ===Surgery=== |
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
- 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.