Trigeminal neuralgia: Difference between revisions
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==Management== | ==Management== | ||
Phenytoin 250 mg IV to abort an acute attack | ===Phenytoin=== | ||
*250 mg IV to abort an acute attack | |||
*Relief lasts from four hours to three days | *Relief lasts from four hours to three days | ||
* | *Fosphenytoin seems to work similarly | ||
===Carbamazepine=== | |||
*First-line agent with 75% success rate initially | *First-line agent with 75% success rate initially | ||
*Proposed Mechanism: Decreases the response of neurons to peripheral stimulation | *Proposed Mechanism: Decreases the response of neurons to peripheral stimulation | ||
| Line 32: | Line 31: | ||
*Posterior fossa microvascular decompressive surgery | *Posterior fossa microvascular decompressive surgery | ||
**Approximately 50% of patients will require surgery | **Approximately 50% of patients will require surgery | ||
*Successful in 70% of patients | |||
Successful in 70% of | |||
==See Also== | ==See Also== | ||
Revision as of 18:38, 3 June 2015
Background
- 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 MRI in these patients to r/o structural etiology
- <5% of patients have V1 distribution, examine carefully for zoster in these patients
Clinical Features
- Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds
- Normal neuro exam
- No pain between paroxysms
- Variant with headache
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
Management
Phenytoin
- 250 mg IV to abort an acute attack
- Relief lasts from four hours to three days
- Fosphenytoin seems to work similarly
Carbamazepine
- First-line agent with 75% success rate initially
- Proposed Mechanism: Decreases the response of neurons to peripheral stimulation
- Started at 100 mg one to two times per day
- Increase by 100-200 mg every 3 days
- Usual maintenance dose is 400-800 mg (rare > 1500 mg)
- Pain relief occurs within several hours to days (94% within 48
hours) - Target serum concentration is 24-43 μmol/L
- If unsuccessful, phenytoin 200-400 mg/day is used in combination
- Other agents: Baclofen, Clonazepam, Valproic acid, Lamotrigine, Gabapentin, Oxcarbazepine, Topiramate
- Posterior fossa microvascular decompressive surgery
- Approximately 50% of patients will require surgery
- Successful in 70% of patients
See Also
References
- J Pain Symptom Manage 2001; 21(6):506-510.