Trigeminal Neuralgia

Diagnostic Approach and A Review of the Therapeutic Options for Trigeminal Neuralgia PNA Headache Council 2007

Major Areas Visited • • • •

Cochrane Library AAN 2007 CPG IHS Library Books – Adams and Victor’s Principles of Neurology – Wolff’s Headache and other head pains – The Headaches (Olesen et al., 2006)

• Journals = 18 papers

Cranial Neuralgias and Central Causes of Facial Pains (IHS) 1.Trigeminal neuralgia 2.Glossopharyngeal neuralgia 3.Nervus intermedius neuralgia 4.Superior laryngeal neuralgia 5.Nasociliary neuralgia 6.Supraorbital neuralgia 7.Other terminal branch neuralgias 8.Occipital neuralgia

Cranial Neuralgias and Central Causes of Facial Pains 9. Neck-tongue syndrome 10. Cold-stimulus headache 11. Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesion 12. Optic neuritis 13. Ocular diabetic neuropathy 14. Head or facial pain attributed to herpes zoster

Trigeminal Neuralgia (TN) or Tic Doloureux

Incidence: • There are 3-5 new cases per 100,000 people per year which is higher in women than man at 3:2 ratio.

Age of onset: • For the Classical (idiopathic) form, they are common at age 52-58 yrs old and 30-35 yrs old for the symptomatic (secondary) forms.

Pathophysiology • Classical (idiopathic) form – There is no known cause for the, however, studies point to an underlying vascular pathology as a cause by irritation over the trigeminal (Gasserian) ganglion.

• Symptomatic (secondary) form, – There are known common causes affecting the CN V

Pathophysiology: Symptomatic (secondary) Form • Compression of the trigeminal ganglion • Demyelinating Disorder (axonal hyperexcitability)

Compression of the Trigeminal Ganglion • Vascular – Tortous atherosclerotic branch of the basilar artery – Basilar artery aneurysm

• Cerebello-Pontine Angle (CPA) Mass – Meningioma – Chordoma – Neurinoma – Metastatic (nasopharyngeal Ca)

Demyelinating Disorder #2 (axonal hyperexcitability) • Multiple sclerosis (MS) – plaques at the nerve root entry • After nerve injury – Post-trauma – Post-dental procedure • Post-mandibular trauma

Demyelinating Disorder #3 (axonal hyperexcitability) • Post-infectious – Herpes zoster – Tympanomastoiditis – Dental carries (microabscesses and pulp degeneration)

• Inflammatory – Connective tissue disease (Sjogren’s Disease)

Clinical Findings/Manifestations: • The facial pain is described paroxysmal, short, jabbing, shooting, electrical like, lancinating, stabbing pain, “red hot needle”, “forked lightning” – Makes the patient wince (tic) or grimace – Graded using the Visual Analog Scale (VAS) of 0/10 without pain to 10/10 with severe pain

• Affects the face unilaterally near the nose or mouth (trigger points)

Clinical Findings/Manifestations: • With no demonstrable sensory nor motor deficits • Attacks may be restricted to 1 or 2 divisiions of the trigeminal nerve – Usually involves the 2nd branch (maxillary) and/or 3rd branch (mandibular) division.

• May have trigger points on face • May be precipitated by chewing, cold/hot drinks, air or touch. • Responds well to antiepileptic drugs (AED)

Diagnostic work-up: • • • • •

Brain MRI / MRA Brain CT / CTA Audiometry Evoked potential studies Cardiac work-up

General Algorithm FACIAL PAIN

History Physical Examination (PE) Neurological Examination (NE)

1. 2. 3. 4. 5.

Clinical

Diagnostic Options: Brain MRI/MRA Brain CT/CTA Audiometry Evoked potentials Cardiac work-up

Symptomatic

Referred

Differential Diagnosis: 1. Demyelinating (MS)  Neurology 2. CPA tumors  Neurosurgery 3. Nasopharyngeal and Paranasal pathology  ENT 4. Dental Pathology  Dentistry 5. Herpes zoster  Neurology 6. Classical  Medications  Neurosurgery 7. Unstable angina  Cardiology

Therapeutic Options • Pharmacologic – Antiepileptic drugs – Non-antiepileptic drugs

• Surgical

WP Collins et al… • Anticonvulsant drugs have been used in the management of pain since the 1960s and the clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning. The Cochrane Collaboration Database, 2006

WP Collins et al… • Anticonvulsants are a group of medicines commonly used for treating “fits” or epilepsy, but which are also effective for treating pain. • The type of pain which responds well is neuropathic pain – Postherpetic neuralgia (shingles) – Painful complications of DM The Cochrane Collaboration Database, 2006

WP Collins et al… • ACs or AEDs are effective for relieving pain caused by damage to nerves, either from injury or disease. • Approximately two-thirds (2/3) of patients who take either carbamazepine or gabapentin can be expected to achieve good pain relief. The Cochrane Collaboration Database, 2006

WP Collins et al. conclusion… • While gabapentin is increasingly being used for neuropathic pain, the evidence would suggest that it is not superior to carbamazepine. The Cochrane Collaboration Database, 2006

Algorithm for the Medical Management of Trigeminal Neuralgia Clonazepam Sodium Valproate Lamotrigine Oxcarbazepine

Taper dose in 4 weeks

Painless for 6 weeks

Pregabalin

With recurrence

Surgical Treament Carbamazepine + Gabapentin

AED +/-

Phenytoin + Baclofen Carbamazepine + Baclofen

Carbamazepine

TN Pain

Phenytoin

Adapted from the lecture of Dr. W. Lopez

Pharmacologic: Antiepileptic Drugs (AED) • • • • • • • •

Carbamazepine Phenytoin Gabapentin Pregabalin Clonazepam Sodium Valproate/Divalproex Lamotrigine Oxcarbazepine

Algorithm for the Medical Management of Trigeminal Neuralgia (TN)

Clonazepam Sodium Valproate Lamotrigine Oxcarbazepine

Taper dose in 4 weeks

Painless for 6 weeks

With recurrence

Pregabalin

Surgical Treament

Carbamazepine + Gabapentin

AED +/-

Phenytoin + Baclofen Carbamazepine + Baclofen

Carbamazepine

TN Pain

Phenytoin

Adapted from the lecture of Dr. W. Lopez

Pharmacologic: NonAntiepileptic Drugs • • • • • • •

Baclofen Tocainide Pimozide Chloripramine Amitriptyline Tizanidine Proparacaine

Li He et al… • Baclofen reduced attacks by 50-75% • Tizanidine reduced the average attacks per day • Pimozide > Carbamazepine • Chlorimipramine > Amitriptyline • Tocainide = Carbamazepine

The Cochrane Collaboration Database, 2006

Conclusion… • No sufficient evidence certifies the efficacy of non-antiepileptic drugs for use in TN • Baclofen, pimozide, tocainide and chlorimipramine has the most potential for use in TN but… • No evidence to recommend use of these non-antiepileptic drugs as routine therapeutics for TN The Cochrane Collaboration Database

Non-pharmacologic: Surgical • Peripheral Neurectomy – supraorbital, infraorbital and mental nerves

• Intracranial trigeminal rhizotomy – portio major

• • • •

Glycerol gasserian gangliolysis Microvascular decompression Stereotactic radiosurgery Radiofrequency rhizotomy

Algorithm for the Surgical Management of Trigeminal Neuralgia Surgical Treatment

Recurrence of Trigeminal Neuralgia

Recurrence of Trigeminal Neuralgia

Medical Treatment

Algorithm for the Surgical Management of Trigeminal Neuralgia (TN)

Surgical Treatment

Recurrence of Trigeminal Neuralgia

Recurrence of Trigeminal Neuralgia

Medical Treatment

Acknowledgement Philippine Neurological Association

HEADACHE COUNCIL Raquel Mallari-Alvarez Martha Lu-Bolanos Regina Macalintal-Canlas Joven Cuanang Carissa Dioquino Raymond Espinosa Ramon S. Javier Ephrain Maranan Philip Ramiro Nannette Domingo-Reyes Artemio Roxas Jr Amado San Luis Socorro Florendo-Sarfati Chair: Servando T. Liban II

Thank you for your kind attention…