facial pain: is it trigeminal neuralgia? -...
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NNC CMUThe Northern Neuroscience Centre
Chiang Mai University
Facial pain: Is it Trigeminal
Neuralgia?
Assist. Prof. Surat Tanprawate, MD Neurology Unit, Chiang Mai University
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Case
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Short gun diagnosis of Trigeminal neuralgia
• TGN remains a clinical diagnosis dependent on a history of sudden shooting or stabbing pain, coming as solitary sensations or paroxysmal and separated by pain-free intervals on unilateral trigeminal nerve division distribution area.
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Pain attributed to lesion or disease of trigeminal nerve (ICHD-III)
Trigeminal neuralgia
Painful trigeminal neuropathy
Classic trigeminal neuralgia
Secondary trigeminal neuralgia
Idiopathic trigeminal neuralgia • Herpes zoster
• Post-herpetic neuralgia
• Post-traumatic • Other disorder • Idiopathic
• Purely, paroxysmal
• concomitant continuous pain
attributed to… • Multiple sclerosis • Space occupying
lesion • Other cause
• Purely, paroxysmal
• concomitant continuous pain
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Classical Trigeminal Neuralgia• Description: Trigeminal neuralgia developing without
apparent cause other than neurovascular compression.
• “Pre-trigeminal neuralgia”: Classical trigeminal neuralgia may be preceded by a period of atypical continuous pain
• “Classical trigeminal neuralgia with concomitant continuous pain: prolong background pain in the affected area
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Key the clinical characteristics of Classic Trigeminal Neuralgia (n=158)
Maarbjerg S, et al. Headache 2014;54:1574-1582
V1 Alone
Concom.persist pain
Sensory abnormality
Autonomic symptome
% of patients0 12.5 25 37.5 50
31
29
49
4
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Vascular compression of Trigeminal nerve
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Trigeminal neuralgia attributed to space occupying lesions and other cause
• Characteristics - similar to TN
• may or may not detect sensory sign
• cause
• space occupying lesion
• other causes - skull base bone deformity, connective tissue disease, AVM, dural AVF, genetic cause of neuropathy or nerve hyper excitability
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Pain attributed to lesion or disease of trigeminal nerve (ICHD-III)
Trigeminal neuralgia
Painful trigeminal neuropathy
Classic trigeminal neuralgia
Secondary trigeminal neuralgia
Idiopathic trigeminal neuralgia • Herpes zoster
• Post-herpetic neuralgia
• Post-traumatic • Other disorder • Idiopathic
• Purely, paroxysmal
• concomitant continuous pain
attributed to… • Multiple sclerosis • Space occupying
lesion • Other cause
• Purely, paroxysmal
• concomitant continuous pain
Typical
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Painful trigeminal neuropathy• Facial pain in the distribution of trigeminal nerve branch by
another disorder and indicative of neural damage
• Pain is continuous or nearly continuous squeezing burning, pin and needle (common), may superimposed by brief pain paroxysms
• Positive (allodynia, hyperalgesia) and negative (hypaesthesia, hypalgesia)
• Causes: herpes zoster, MS, space-occupying lesion, systemic disease
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Case 2.
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Classic trigeminal neuralgia, Typical
Rare
Intraoral or extraoral in trigeminal region
Each episode of pain lasts for seconds to minutes; refractory periods, and long periods of no pain
Sharp, shooting, moderate to very severe
Light touch provoked (e.g., eating, washing, talking)
Discrete trigger zones
Atypical trigeminal neuralgia
Rare
Intraoral or extraoral in trigeminal region
Sharp attacks lasting seconds to minutes, more continuous-type background pain, less likely to have complete pain remission
Sharp, shooting, moderate to severe but also dull, burning, continuous mild background pain
Light touch provoked, but continuous-type pain not so clearly provoked
May have small trigger areas, variable pattern
Trigeminal neuropathy Very rare
Trigeminal area, but may radiate beyond
ContinuousDull with sharp exacerbation
Areas of allodynia, light touch
Sensory loss, subjective-objective, progressive, vasodilation and swelling may occur
Adapted from Essentials of physical medicine and rehabilitation: musculoskeletal disorders, pain, and rehabilitation/ [edited by] Walter R. Frontera, Julie K. Silver, Thomas D. Rizzo Jr.—2nd ed. Chapter 90.
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Cranial neuralgia other than trigeminal nerve distribution
Supraorbital neuralgia
Trigeminal neuralgia Glossopharyngeal neuralgia
Nervus intermedius neuralgia
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Trigeminal neuralgia Trigeminal neuropahty
Trigeminal autonomic neuralgia (TACs)
Other neuralgia
Other facial pain
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Persistent Idiopathic Facial Pain (PIFP) or Atypical facial pain
• Description:
• Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours/day over more than 3 months, in the absence of clinical neurological deficit.
• Pain characters:
• poorly localized, and not following the distribution of a peripheral nerve
• dull, aching or nagging quality
• Diagnostic by exclusion
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Facial pain other than neuralgia
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Trigeminal Autonomic Cephalalgias• A group of primary headache characterised by strictly
unilateral headache pain that occurs in association with ipsilateral cranial autonomic features
• Cluster headache (CH)
• Paroxysmal hemicrania (PH)
• Short-lasting unilateral neuralgiform headache attack with conjunctival injection and tearing/cranial autonomic features (SUNCT/SUNA)
• Hemicrania continua (HC)
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Cohen AS. Headache 2007
TACs subtypes
Prevalence 56/100,000 Very rare, not known Very rare, not known
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Overlap between attack duration in trigeminal autonomic cephalalgias
Leone M, Bussone G. Lancet Neurol 2009; 8: 755–64
“Longer name, shorter duration”
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Paroxysmal hemicrania
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Clinical feature• Side, location, severity, character of
pain
• ophthalmic distribution, can be extra-trigeminal- occiput, neck, shoulder, arm
• strictly unilateral and without side shift
• excruciating pain
Attacks are prevented completely by therapeutic doses of indomethacin
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Indomethacin testoral indomethacin should be initiated at 25 mg tid.
increase to 50 mg tid.10 days
increase to 75 mg tid. 10 days
if no or partial response
if no or partial response
Dodick, Silberstein SD. Wolff’s headache 3 ed.
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1 week After Indomethacin test
“Paroxysmal Hemicrania”
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Indomethacin responsive headache• Paroxysmal hemicrania
• Hemicrania continua
• Hypnic headache
• Primary exertional headache
• Primary cough headache
• Primary stabbing headache (jabs and jolts syndrome)
• Primary headache associated with sexual activity
Dodick WD. Current Pain and Headache Reports 2004, 8:19–26
Unclear mechanism:inhibit Nitric oxide??
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SUNCT/SUNA
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ICHD-III
SUNCT criteria
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43 SUNCT and 9 SUNA were
studied
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Great mimicker: Trigeminal neuralgia
67% of patient has at least 1 autonomic symptomV1 - conjunctival injection, ptosis, excessive tearing
Simms HN, Honey CR. J Neurosurg 2011 Aug;115(2):210-6.
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SUNCT vs Trigeminal neuralgia
SUNCT: very short duration of attack, precipitate attacks by touching certain trigger zones within trigeminal innervated
TN: very short duration, can be V1 +/- autonomic distribution
Matharu MS. J Neurol Neurosurg Psychiatry 2002;72(Suppl II):ii19–ii26
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NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Other primary headache that mimic TN• Primary stabbing headache ;- previous term Ice-pick pains;
jabs and jolts; needle-in-the-eye syndrome; ophthalmodynia period- ica; sharp short-lived head pain
• Transient and localized stabs of pain in the head that occur spontaneously in the absence of organic disease of underlying structures or of the cranial nerves
• Involve extra-trigeminal region in 70%
• 80% of stabs last three seconds or less; rarely, stabs last for 10–120 seconds.
• Common in migraine
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NNC CMUThe Northern Neuroscience Centre
Chiang Mai University
Thank you for your attention