Trigeminal Neuralgia Disease

DESCRIPTION

A disorder of the sensory nucleus of the 5th cranial nerve (trigeminal nerve), producing episodic, paroxysmal, severe lancinating pain lasting seconds to minutes followed by a pain free period in the distribution of one or more of its divisions. Often precipitated by stimulation of well-defined, ipsilateral trigger zones, usually perioral, perinasal, occasionally intraoral (eg washing, shaving).

System(s) affected: Nervous
Genetics: N/A
Incidence/Prevalence in USA: 16/100,000
Predominant age: Over age 50, peak age 60, rare before age 35
Predominant sex: Female > Male (2:1)

SIGNS AND SYMPTOMS

Unilateral (< 4% bilateral, rarely at the same time; bilateral mostly in MS), symptoms rarely present at night
Excruciating lip pain
Excruciating gum pain
Excruciating cheek pain
Paroxysmal facial pain
Wincing
Pain elicited by tickle or touch
Flushing
Lacrimation
Salivation
Pain "bursts" several seconds to minutes with refractory period after
Right > left side preference
2nd > 3rd >> 1st (less than 5%) division trigeminal nerve most commonly affected

CAUSES

When present, most commonly compression of the trigeminal nerve by anomalous arteries or veins of the posterior fossa, usually the superior cerebral artery compressing the trigeminal root
Etiology classification
- Idiopathic
- Secondary - disseminated sclerosis; cerebellopontine angle tumors, e.g., meningioma; tumors of the 5th nerve, e.g., neuroma, vascular malformations

RISK FACTORS

Unknown

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Semilunar ganglion - inflammatory changes
Degenerative changes

SPECIAL TESTS

N/A

IMAGING

N/A

DIAGNOSTIC PROCEDURES

MRI or CT scan - neoplasm in cerebellopontine angle must be ruled out. Special MRA technique of collapsed MRA superimposed on routine spin echo T-1 weighted images.

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Drug treatment is first approach. Invasive procedures for patients who cannot tolerate, or fail to respond to, drug treatment.
Avoidance of stimulation (air, heat, cold) of trigger zones (lips, cheeks, gums)
4% tetracaine dissolved in 0.5% bupivacaine nerve block (only a few case reports to date)
25-50% of TN patients eventually fail medical treatment
Alcohol block or glycerol injection into the trigeminal cistern - unpredictable side effects (dysesthesia and anesthesia dolorosa); temporary

SURGICAL MEASURES

Microvascular decompression of the 5th cranial nerve at its entrance to (or exit from) the brainstem (70-90% effective)
Partial sensory rhizotomy
Peripheral block or section of 5th nerve proximal to the Gasserian ganglion
Gamma knife radiosurgery (minimally invasive, 77% significant relief)
Balloon compression of the Gasserian ganglion (especially effective for 1st division TN pain)
Peripheral nerve ablation
- Radiofrequency thermocoagulation (possibly 90-97% partial or complete relief; recurrence rate is unknown)
- Neurectomy
- Cryotherapy - good initial results; considerable relapse rate

ACTIVITY

Full activity

DIET

No special diet

PATIENT EDUCATION

Instruct regarding medication dosage and side effects

PREVENTION/AVOIDANCE

Reduce drugs after 4-6 weeks to determine if condition is in remission, resume at previous dose if pain recurs. Withdraw drugs slowly after several months again to check for remission or if lower dose of drugs can be tolerated.

POSSIBLE COMPLICATIONS

Mental and physical sluggishness, dizziness with carbamazepine

EXPECTED COURSE AND PROGNOSIS

Exacerbations in fall and spring; otherwise good

ASSOCIATED CONDITIONS

Sjögren's syndrome
Rheumatoid arthritis
Chronic meningitis
Facial migraine
Acute polyneuropathy
Multiple sclerosis
Hemifacial spasm
Pretrigeminal neuralgia

AGE-RELATED FACTORS

Pediatric: Unusual in childhood
Geriatric: N/A
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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