Trigeminal Neuralgia

Key Features

Essentials of Diagnosis

• Brief episodes of stabbing facial pain

• Pain is in the territory of the second and third division of the trigeminal nerve

• Pain exacerbated by touch

General Considerations

• Trigeminal neuralgia (tic douloureux) is most common in middle and later life

• It affects women more frequently than men

• Pain may be due to an anomalous artery or vein impinging on the trigeminal nerve

Clinical Findings

Symptoms and Signs

• Momentary episodes of sudden lancinating facial pain

• Commonly arises near one side of the mouth and shoots toward the ipsilateral ear, eye, or nostril

• The pain may be triggered by touch, movement, drafts, and eating

• To prevent further attacks, many patients try to hold the face still

• Symptoms remain confined to the distribution of the trigeminal nerve (usually the second or third division) on one side only

• Neurologic examination shows no abnormality unless trigeminal neuralgia is symptomatic of some underlying lesion, such as multiple sclerosis or a brainstem neoplasm

Differential Diagnosis

• Atypical facial pain

  • Especially common in middle-aged women

  • Generally a constant burning pain that may have a restricted distribution at onset but soon spreads to the rest of the face on the affected side and sometimes involves the other side of the face, the neck, and the back of the head as well

• Temporomandibular joint dysfunction

  • Occurs with malocclusion, abnormal bite, or faulty dentures

  • May cause tenderness of the masticatory muscles

  • An association between pain onset and jaw movement

  • Diagnosis requires dental examination and x-rays

• Giant cell arteritis—may have pain on mastication

• Sinusitis and ear infections

• Glaucoma

• Multiple sclerosis

• Brainstem tumor

• Dental caries or abscess

• Otitis media

• Glossopharyngeal neuralgia

• Postherpetic neuralgia

Diagnosis

Imaging Studies

• Brain MRI

  • Need only be obtained when a secondary cause is suspected

  • Usually normal in classic trigeminal neuralgia

Diagnostic Procedures

• The characteristic features of the pain in trigeminal neuralgia usually distinguish it from other causes of facial pain

• In a patient younger than 40 years presenting with trigeminal neuralgia, multiple sclerosis must be suspected even if there are no other neurologic signs

Treatment

Medications

• Carbamazepine (200–600 mg twice daily orally or oxcarbazepine (300–600 mg twice daily orally) is most helpful (monitor blood cell counts and liver biochemical tests)

• Phenytoin 200–400 mg once daily orally is second choice

• Baclofen (10–20 mg three or four times daily orally), topiramate (50 mg twice daily orally), or lamotrigine (400 mg daily orally) may be helpful, alone or in combination with carbamazepine or phenytoin

• Gabapentin

  • Up to 3600 mg daily orally ...