TRIGEMINAL NEURALGIA MIGRAINES

CERVICAL PAIN

MASTER CLASS 2013

MACRO-ANATOMY

“Neuralgias of the head”

Facial Neuralgias

Trigeminal Neuralgia

Atypical Trigeminal Neuralgia

Atypical Facial Pain

Anesthesia Dolorosa

Cluster headaches

Tension headaches

Sinus headaches

Migraine headaches with or

without aura

Cephalgia

HOW TO TREAT?

“Regional neuropathic pain syndrome”

of the

Trigeminal, Facial and Cervical nerves

TRIGEMINAL NERVES

FACIAL NERVE

POSTERIOR SUPRACLAVICULAR NERVE

OCCIPITAL NERVES

Encyclopedia Anatomica 1771

Nerves involved in “Trigeminal Neuralgia,

headaches, sinusitis and migraines”

John Marshall (1883):

”Neuralgia is most likely where the nerves leave

the bony or fibrous framework or around

bones”

GRAY’ ANATOMY

Gray’s Anatomy

of the Facial

nerve and branches

FACIAL-TRIGEMINAL ANASTOMOSIS

Spalteholz Anatomy Trigeminal

Facial Cervical nerves

Hebb’s postulate

(1949): “nerves that fire

together, wire together”

Encyclopedia Anatomica: Right Facial nerve Hilton’s law (1863):

”The joints and muscles acting on them and the overlying skin share a nerve supply”

CERVICAL PLEXUS LAST’S ANATOMY

Superficial nerves neck Last’s Anatomy

The Greater Auricular nerve (C2-3) anastomosing with

the Facial nerve (VII) provides it’s perineurium with Nervi Nervorun (sensocrine innervation)

The Greater Auricular nerve (C2-3) anastomosing with the Facial nerve (VII) provides it’s perineurium with Nervi

Nervorum (sensocrine innervation)

“Punctus Nervosum” on the posterior supraclavicular nerve

is a prime headache “Trigger Point”

Ophtalmic nerve (V1)

Maxillary nerve (V2)

Mandibular nerve (V3)

Trigeminal Nerve Paired cranial nerve with three major branches:

Facial Nerve and Artery Last’s Anatomy

Trigeminal Nerve Divisions I, II & III Last’s Anatomy, ninth Edition, McMinn

STEP ONE: Palpate and mark the pain sites on the three (3) Trigeminal foramen V1,V2,V3. Then inject 0,5 ml of DW5 with a 30G ½ inch needle

STEP TWO Mark all the tender spots along the trigeminal nerve branches. Inject these tender sites using 0.5 ml of D5W. If completely pain-free, pathology is caused by a pure Trigeminal Nerve involvement. If not completely pain-free, consider a mix Facial ,Trigeminal and Cervical Neuralgia and proceed to Step Three.

STEP THREE Locate and palpate gently for the tender spots along the five major Facial and/or Cervical nerve branches

“Differential Diagnosis”

of Craniofacial Pain

Primary and secondary headache disorders

Ophthalmologic

Ear, nose, and throat

Sinus disorders

Teeth and jaw (TMJ)

Oral cavity and salivary glands

Craniocervical

Neoplasia (intra/extra-cranial)

Psychogenic (DSM-IVR)

Trigeminal Neuralgia Patients Treated

with Neural Proloterapy

Ferrara, Italy 2011

Dr Steven Cavallino

The Italian Twelve

7/12 were actual Trigeminal Neuralgias (V2-V3)

Only 1/7 also showed pain in opthalmic branch

(V1)

The Italian Twelve

Neural Prolotherapy Injection Sites

in Facial Neuralgia

Red ………Trigeminal Nerve Injection Sites (V1,V2, V3)

Yellow ……Temporal Nerve Injection Sites

Blue ………Facial Nerve Injection Sites

All 12

patients

showed an

immediate

pain relief

following

initial NPT

treatment

The Italian Twelve

Patients returned weekly for a total of 3 NPT treatments

9 /12 patients (75%) showed less pain and decreased

frequency after first treatment with NPT ( DW5)

The pain scale was 3/10 after one week and was 1/10 after the

second week

The remaining 3 patients (25%) that were still 6/10 after one

treatment needed more attention and treatment. After 3

treatments they were 1/10.

The Italian Twelve

Christchurch Thirteen

From August 2011

Christchurch Thirteen

• All thirteen had an immediate and complete resolution of their pain

• Two patients with an ‘isolated’ Trigeminal neuralgia. One patient with a 30 year Hx of TN after dental work did not want to continue after two treatments, “too difficult”. One patient, age 72, with a 9 year Hx of TN of the Maxillary branch after chiropractic manipulation, had lasting relief after two treatments but was diagnosed with disseminated Ca breast and hasn’t returned.

• One 9 year old girl with a 18 month Hx of chronic frontal and parietal headaches following ‘headers’ in a game of football, had instant relief, but this didn’t last. She fractured her Tibia during the treatment period and was in a great deal of associated pain and disability. BMI very high.

• Six patients with ‘stinking headaches’ resolved with one treatment.

• Four mixed TN, Facial, Cervical neuralgia’s responded instantly. One female patient age 48 with a 20 year Hx of ‘TN’ has come back every month and is without medication. One female patient age 42 with a 30 year Hx of ‘TN’ returned after 4 months of no headaches and requested a ‘top-up’, “just in case”. One female patient age 45 with a’ lifelong Hx’ of TN has been back 3 times since August and is no longer on any medication. One female patient, age 36, had instant relief but did not return. “too painful”

Christchurch three with ‘sinus pain’

• One male patient, age 48, had three previous sinus operations, but still with pain and ‘snorting and sniffing’. Wife C/O his snoring. Has had two Rx’s and reports no more ‘sinus pain’, ‘wife happy’ and not ‘sniffing’ anymore. Treatment of all TN branches and some Facial branches

• One male patient, age 36 with 2 previous sinus operations, but still with ‘sinus pain’ responded with one treatment of TN I and II.

• One female patient with a Hx of 3 previous operations was lost to follow up. TN 1 and II were treated.