| Trigeminal neuralgia (Tic
douloureux) |
| Overview |
 | Most common paroxysmal pain of the face |
| Incidence: 4-5/100,000 population. |
| 1% of MS patient |
| Etiology: not clear
 | 1-2% has posterior fossa lesion, tends to be younger patients. |
| Rest is idiopathic |
|
| Most patients > 50 yo, female more than male. |
| Post-traumatic trigeminal neuralgia:
| 5 to 10% after facial trauma or oral surgery. |
| May represent trigeminal "neuroma" or deafferentation pain.
This diagnosis overlaps substantially with atypical facial pain. |
|
|
| Signs & Symptoms |
| Brief, recurrent electric like pain |
| Trigger zone over skin or mucous membrane |
| Usually involves a single Trigeminal division, at times 2 adjacent ones |
| 4% bilateral involvement: suspect multiple sclerosis |
| Triggering stimuli includes talking, eating, toothbrushing, and wind or
cold temperatures on the face. |
| Spontaneous remissions common |
|
| Medical Treatment of
Trigeminal Neuralgia |
| Carbamazepine 100-200 mg bid, titrate up. Monitor WBC, may cause
leukopenia. |
| Gabapentin (Neurontin) may be effective.
| 300 mg per day, titrate up by 300 mg every 2 to 3 days, given qid until
relief is achieved. |
| Some patients can tolerate up to 4000 mg per day |
|
| Baclofen 5-10 mg tid, up to 60 mg / day |
| 70% of patients respond at least initially to medical management. As time
goes on, the drugs become less effective in many patients. |
|
| Surgical treatment of
Trigeminal Neuralgia |
| Percutaneous procedures:
| Less risk |
| local or brief general anesthesia |
| A needle or trocar is inserted on the cheek just lateral
to the corner of the mouth, under fluoroscopic guidance, introduced into the ipsilateral
foramen ovale. |
| Gangliolysis is performed. |
| Different types of procedure
 | Percutaneous radiofrequency trigeminal gangliolysis (PRTG) |
| Percutaneous retrogasserian glycerol rhizotomy (PRGR) |
| Percutaneous balloon microcompression (PBM). |
|
|
| Microvascular decompression:
| Requires general anesthesia |
| 2.5- to 3-cm craniectomy is performed, the dura is opened, and the
cerebellum is microsurgically retracted. |
| Typically, an artery or other vascular cross-compression of the nerve is
identified, the vascular structure is padded away from the nerve with
polytetrafluoroethylene (Teflon) felt. |
| This operation has a low mortality rate 0.1 and 0.5% in most series. |
| Serious morbidity probably between 1 and 5%.
| numbness, hearing loss, dizziness, cerebellar syndrome, CSF leaks,
meningitis, diplopia. |
|
|
| Expected pain-free interval
| PRGR or PBM: approximately 1.5 to 2 years |
| PRTG: about 3 to 4 years |
| Microvascular decompression: pain relief can be expected to last an
average of 15 years. |
|
| Further reading
|
|
| Glossopharyngeal neuralgia |
| Overview |
| Brief, electric like pain around tonsil & ear |
| Relatively rare |
| Consider skull base tumor |
| ENT evaluation to rule out occult neoplasm |
|
| Treatment |
| If no evidence of compressive lesion, medical treatment similar to
Trigeminal Neuralgia |
|
| Ophthalmic herpes zoster & post
herpetic neuralgia |
| Overview |
| From reactivation of latent virus in Trigeminal sensory ganglion |
| Patient with severe pain and over 80 yo more prone to develop post
herpetic neuralgia |
|
| Signs & Symptoms |
| Nausea, malaise, fever in acute phase |
| Burning or lacinating pain in V1 distribution |
| Watch for corneal ulceration |
| May have residue scar & sensory deficit |
|
| Test |
| Rising Herpes Zoster antibody titer |
|
| Treatment |
|
| Atypical facial pain |
| Overview |
| Facial pain, no organic etiology found |
| Most common in middle age female |
|
| S/S |
| Deep, poorly localized pain |
| Aching, drawing all the time, "pain is ruining my life". |
| Mood swings, irritability, insomnia common. |
| Examination negative except for some tenderness on face. |
| Failed multiple medications & procedures, seen multiple specialists. |
|
| Treatment |
| Difficult, ?antidepressant |
|
| Cluster headache |
| Review |
see cluster headache page |
| Temporomandibular joint
disorder |
| Overview |
| Diagnosis is controversial & difficult. |
| Many patients who have dental malocclusion but do not have TMJ. |
| Many asymptomatic patients have abnormal imaging study. |
| Joint tenderness & EMG abnormality occur with equal frequency for
patients & control. |
|
| Treatment |
| ?antidepressant |
|
| Temporal arteritis |
| Review |
|
| Other disorders causing facial
pain |
| Paranasal sinus disease |
| Acute sinusitis is usually evident |
| Chronic sinusitis, especially sphenoid sinusitis may be difficult to
diagnose. |
| ?MRI of head |
|
| Optic neuritis |
| Retro-orbital pain with color desaturation of the affected eye |
|
| Ocular pain |
| Glaucoma |
| Uveitis |
|
| Thalamic pain |
| Central pain such as from small infarct |
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