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Trigeminal neuralgia
From WikEM
Contents
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
- More common in Middle aged women
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- 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
- Temporal arteritis
- Idiopathic intracranial hypertension (aka Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
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
- Varicella
- Herpes
- Enterovirus
- West Nile
- Tuberculosis
- Lyme disease
- Syphilis
- Drug induced aseptic meningitis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
- Sarcoidosis
- Vasculitis
- Connective tissues disease
Facial paralysis
- Bell's Palsy
- CVA
- Trigeminal neuralgia
- Tick paralysis
- Herpes zoster oticus (Ramsay Hunt syndrome)
- CNS tumor
- Acoustic neuroma or other cerebellopontine angle lesions
- Meningioma
- Cerebellar pontine angle
- Facial nerve schwannoma
- Parotid
- Sarcoma
- Anesthesia nerve blocks
- Cerebral Aneurysms (vertebral, basilar, or carotid)
Evaluation
- 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 CT/MRI in these patients to rule out structural etiology
- <5% of patients have V1 distribution, examine carefully for zoster in these patients
Management
Phenytoin
- 250mg 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 100mg one to two times per day
- Increase by 100-200mg every 3 days
- Usual maintenance dose is 400-800mg (rare >1500mg)
- Pain relief occurs within several hours to days (94% within 48 hours)
- Target serum concentration is 24-43 μmol/L
- If unsuccessful, phenytoin 200-400mg/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
Disposition
- Typically outpatient
See Also
References
- J Pain Symptom Manage 2001; 21(6):506-510.
