Trigeminal neuralgia: Difference between revisions
Ostermayer (talk | contribs) (Text replacement - "Category:Neuro" to "Category:Neurology") |
Neil.m.young (talk | contribs) (Text replacement - "== " to "==") |
||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
== Clinical Features == | ==Clinical Features == | ||
*Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds | *Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds | ||
*Normal neuro exam | *Normal neuro exam | ||
Line 42: | Line 42: | ||
*[[Headache]] | *[[Headache]] | ||
== References== | ==References== | ||
*J Pain Symptom Manage 2001; 21(6):506-510. | *J Pain Symptom Manage 2001; 21(6):506-510. | ||
[[Category:Neurology]] | [[Category:Neurology]] |
Revision as of 14:51, 9 July 2016
Background
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
Diagnosis
- 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
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
Surgery
- 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.