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Introduction to Introduction to Trigeminal Neuralgia Trigeminal Neuralgia Teekayu Plangkoon Plangkoon J J RNS RNS

  1. Introduction to Introduction to Trigeminal Neuralgia Trigeminal Neuralgia ฑีฆายุ พลางกูร พลางกูร จอรนส จอรนส ฑีฆายุ Teekayu Plangkoon Plangkoon J JÖ ÖRNS RNS Teekayu

  2. Objectives Objectives Historical background of the condition Historical background of the condition Epidemiology Epidemiology Clinical features Clinical features Pathophysiology of TN of TN Pathophysiology Diagnostic criteria and differential Diagnostic criteria and differential diagnosis diagnosis Clinical assessment of TN Clinical assessment of TN

  3. Historical Background Historical Background th century Arab physician 11 th century Arab physician Jurjani Jurjani (1066 (1066 – – 11 1136)’ ’s book s book 1136) “ There is a type of pain which effects the teeth on one There is a type of pain which effects the teeth on one “ side and the whole of the jaw on the side which is side and the whole of the jaw on the side which is painful. With the pain there is spasm of the face and painful. With the pain there is spasm of the face and severe anxiety… severe anxiety ….. .. The cause of spasm and anxiety is The cause of spasm and anxiety is the proximity of the artery to the nerve. .” ” the proximity of the artery to the nerve Nicolaus Andr André é (1756) described 5 cases (1756) described 5 cases Nicolaus tic douloureux douloureux (unbearably painful twitch) (unbearably painful twitch) tic

  4. Historical Background Historical Background John Fothergill (1773) – – published a full published a full John Fothergill (1773) account of tic douloureux and presented a and presented a account of tic douloureux paper to the medical society of London paper to the medical society of London Fothergill’ ’s disease s disease Fothergill (Dolor Faciei Faciei Fothergillii Fothergillii) ) (Dolor Pujol (1787) discussed the diagnostic (1787) discussed the diagnostic Pujol confusion of tic douloureux and and pain of pain of confusion of tic douloureux dental origin dental origin

  5. Historical Background Historical Background Charles Bell (1829) confirmed that Charles Bell (1829) confirmed that trigeminal nerve (the V nerve) was was trigeminal nerve (the V nerve) identified as a distinct nerve from facial identified as a distinct nerve from facial nerve. nerve. Trigeminal Neuralgia (TN) Trigeminal Neuralgia (TN)

  6. Epidemiology of TN Epidemiology of TN TN is a rare condition TN is a rare condition (incidence = 4.5 / 100,000) (incidence = 4.5 / 100,000) The peak incidence is in 60- -70 age group 70 age group The peak incidence is in 60 Women are more likely to get TN Women are more likely to get TN At increased risk of developing TN are patients At increased risk of developing TN are patients with multiple sclerosis multiple sclerosis (MS is seen in 2 (MS is seen in 2- -4 % of 4 % of with TN patients) and hypertension hypertension TN patients) and Zakrzewska JM, JM, Hamlyn Hamlyn PJ. Facial pain. Epidemiology of Pain. IASP, Seattle, WA, PJ. Facial pain. Epidemiology of Pain. IASP, Seattle, WA, Zakrzewska 1999: 171- -202 202 1999: 171

  7. Clinical features Clinical features Character of pain Character of pain Radiation Radiation Site Site Severity Severity Onset of pain Onset of pain Provoking factors Provoking factors Relieving factors Relieving factors

  8. Character of pain Character of pain Sharp , shooting , Sharp , shooting , stabbing, unbearable, like stabbing, unbearable, like lightning or an electric lightning or an electric shock, cattle prod shock, cattle prod McGill Pain McGill Pain Questionnaires (MPQ), Questionnaires (MPQ), 78 adjective words 78 adjective words describing pain describing pain (Melzack Melzack, 1975) , 1975) (

  9. Melzack R, Terrence C, Fromm G, Amsel R . Trigeminal neuralgia and atypical facial pain: use of the McGill Pain Questionnaire for discrimination and diagnosis. Pain 1986; 27(3):297-302

  10. Site and Radiation Site and Radiation Distribution of trigeminal Distribution of trigeminal nerve nerve Nearly always unilateral Nearly always unilateral Total right 61% , Total left Total right 61% , Total left 36%, Total bilateral 3% 36%, Total bilateral 3% V1 = 4% V1 = 4% V2 = 17% V2 = 17% V3 = 15% V3 = 15% V1+V2 = 14% V1+V2 = 14% V2+V3 = 32% V2+V3 = 32% V1+V2+V3 = 17% V1+V2+V3 = 17%

  11. Likely sites of trigger TN pain Likely sites of trigger TN pain

  12. Severity Severity TN pain can be TN pain can be suicidal suicidal The MPQ shows The MPQ shows both sensory and both sensory and affective elements are affective elements are high high VAS (Visual Analogue VAS (Visual Analogue Scale) Scale)

  13. Timing , duration and onset Timing , duration and onset Paroxysmal attack and a pain- -free (refractory) free (refractory) Paroxysmal attack and a pain intervals between attacks, memorable first attack intervals between attacks, memorable first attack Pain of abrupt onset and equally abrupt termination Pain of abrupt onset and equally abrupt termination Remission period Remission period

  14. Differences between TN and Differences between TN and neuropathic pain pain neuropathic Paroxysmal with long pain free intervals Paroxysmal with long pain free intervals No abnormal sensations No abnormal sensations No build up of pain, refractory periods No build up of pain, refractory periods Responds to surgical treatment Responds to surgical treatment

  15. Provoking and relieving factors Provoking and relieving factors Provoking Relieving Provoking Relieving - Light touched Light touched - Rest and relaxation Rest and relaxation - - provoked i.e. provoked i.e. - Local Local anaesthetic anaesthetic - washing, shaving, washing, shaving, agent agent smoking, talking, smoking, talking, - Anticonvulsants Anticonvulsants - drinking, brushing drinking, brushing (carbamazepine carbamazepine) ) ( teeth, making up teeth, making up - Surgery Surgery - - Mechanical Mechanical - - Spontaneous Spontaneous - - Thermal Thermal - remisssion remisssion

  16. Why is the right diagnosis Why is the right diagnosis important? important? Proper managements and referrals Proper managements and referrals Recruit patients into trials Recruit patients into trials “Words matter, because what you describe will make a Words matter, because what you describe will make a “ ” different in treatment ” different in treatment - Dr Kim - Dr Kim Burchiel Burchiel, chief of neurosurgery, Oregon Health Sciences University, , chief of neurosurgery, Oregon Health Sciences University, Oregon, USA Oregon, USA “Before we start giving a lot of medicines, we ought to be Before we start giving a lot of medicines, we ought to be “ ” sure of the diagnosis ” sure of the diagnosis - Dr Joanna - Dr Joanna Zakrzewska Zakrzewska, Oral Medicine, , Oral Medicine, Barts Barts and The London School of and The London School of Medicine and Dentistry, London, UK Medicine and Dentistry, London, UK

  17. Trigeminal Neuralgia Trigeminal Neuralgia IASP Classification (1994) IASP Classification (1994) Sudden, severe, brief, recurrent stabbing Sudden, severe, brief, recurrent stabbing pain in the distribution of the trigeminal pain in the distribution of the trigeminal nerve (IASP, 1994) (IASP, 1994) nerve 1. Trigeminal neuralgia (Tic Trigeminal neuralgia (Tic Douloureux Douloureux) ) 1. 2. Secondary trigeminal neuralgia from Secondary trigeminal neuralgia from 2. CNS lesions CNS lesions 3. Secondary trigeminal neuralgia from Secondary trigeminal neuralgia from 3. facial trauma facial trauma

  18. Diagnostic Criteria of Trigeminal Diagnostic Criteria of Trigeminal Neuralgia by the IHS (2004) Neuralgia by the IHS (2004) 1. Classical trigeminal 1. Classical trigeminal neuralgia neuralgia 2. Symptomatic 2. Symptomatic trigeminal neuralgia trigeminal neuralgia Cephalalgia,2003 vol. 24 suppl suppl 1, 1, Cephalalgia,2003 vol. 24 pp. 126- pp. 126 -127 127

  19. Diagnostic Criteria of TN (2004) Diagnostic Criteria of TN (2004) Classical trigeminal neuralgia Classical trigeminal neuralgia The International Headache Society (IHS) The International Headache Society (IHS) Paroxysmal attacks of pain (fraction of a second Paroxysmal attacks of pain (fraction of a second to 2 minutes) to 2 minutes) Pain has at least one at least one of the following of the following Pain has characteristics characteristics – Intense, sharp, superficial or stabbing Intense, sharp, superficial or stabbing – – Precipitated from trigger areas or by trigger factors Precipitated from trigger areas or by trigger factors – Attacks are stereotyped Attacks are stereotyped No clinically evident neurological deficit No clinically evident neurological deficit Not attributed to another disorder Not attributed to another disorder

  20. Atypical Trigeminal Neuralgia Atypical Trigeminal Neuralgia (TN Type II) (TN Type II) Sharp but also burning aching background Sharp but also burning aching background pain pain Pain can persist over 2 minutes Pain can persist over 2 minutes They tend to benefit less from They tend to benefit less from interventional treatments interventional treatments refractory pain free period

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