Trigeminal Neuralgia

• Trigeminal neuralgia is inflammation of the trigeminal nerve, causing intense facial pain, paroxysmal, sharp pain and follow by lacrimation, facial spasm.

• It is also known as tic douloureax because the intense pain can cause patients to control their face into a grimace and cause the head to move away from the pain

Causes trigeminal neuralgia

• Most often, the cause of trigeminal neuralgia is idiopathic,

• There are some instances when the nerve can be compressed by nearby blood vessels, aneurysms, or tumors.

Causes trigeminal neuralgia

• There are inflammatory causes of trigeminal neuralgia because of systemic diseases including multiple sclerosis, sarcoidosis, and Lyme disease.

• There also is an association with collagen vascular diseases including scleroderma and systemic lupus erythematosus.

Symptoms of trigeminal neuralgia

• Acute onset of sharp, • Stabbing pain to one side of the face. • It tends to begin at the angle of the jaw

and radiate along the junction lines;

• Between the ophthalmic branchV1 and maxillary branch V2, or the maxillary branch V2 and the mandibular branch V3.

Symptoms of trigeminal neuralgia

• The pain is severe and described as an electric shock.

• It may be made worse by light touch, chewing, or cold exposure in the mouth.

• In the midst of an attack, affected individuals shield their face trying to protect it from being touched.

• This is an important diagnostic sign because with many other pain syndromes like a toothache, the person will rub or hold the face to ease the pain

Symptoms of trigeminal neuralgia

• While there may be only one attack of pain, the person may experience recurrent sharp pain every few hours or every few seconds.

• Between the attacks, the pain resolves completely and the the person has no symptoms.

• However, because of fear that the intense pain might return, people can be quite distraught.

• .

Symptoms of trigeminal neuralgia

• Trigeminal neuralgia tends not to occur when the person is asleep, and this differentiates it from migraines, which often waken the person

• After the first episode of attacks, the pain may subside for months or years but there is always the risk that trigeminal neuralgia will recur without warning.

The International Headache Society has established criteria for making the diagnosis

and includes the following

1. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve

2. Pain has at least one of the following characteristics: (1) intense, sharp, superficial or stabbing; or (2) precipitated from trigger areas or by trigger factors

3. Attacks stereotyped in the individual patient

4. No clinically evident neurologic deficit

5. Not attributed to another disorder

Triggers

• Shaving• Stroking your face• Eating• Drinking• Brushing your teeth• Talking• Putting on makeup• Encountering a breeze• Smiling• Washing your face

Gbr Klinik:

• Insidens 4,3 per 100.000 populasi /tahun • Perempuan > laki: 1,17 : 1 • Sering pada usia dewasa setelah 40 thn,

ditemukan juga pada anak usia 12 thn. • Nyeri tajam menusuk seperti kesetrum

listrik -> 20-30 detik secara paroksismal.• Unilateral (97%) dapat bilateral • Paling sering pada cabang ke 2 & 3,• Presipitasi mengunyah, menggigit,kontak

pada daerah trigger zone.

Rasa Nyeri

Reseptor nosiseptif miofasial

Serabut aferent urutan pertama (first order)

Nervus Trigeminus

Gangglion Trigeminus

Brainstem setinggi Pons

Berakhir TNC

Neuron Aferent urutan kedua (second order)

Neuron Aferent urutan ketiga (third order)

Korteks somatosensoris Korteks somatosensoris sekunder

Anatomi Transmisi Impuls

Cab. Segmen SpinalisCervical atas C1 – C2

Medulary dorsal horn (MDH)= Spinal Dorsal Horn (SDH)

• Pada saat ini belum ada tes yang reliabel dalam mendiagnosa trigeminal neuralgia.

• Jadi diagnosa trigeminal neuralgia dibuat berdasarkan anamnesa pasien secara teliti dan cermat. {Zakrzewska,1995}

Treatments and drugs

• Medications– Anticonvulsants

• Karbamasepin • Phenytoin• Klonazepam • As. Valproat • Baclofen

– Antispasmodic agents

treatment for trigeminal neuralgia

• Idiopathic trigeminal neuralgia most often is treated with good success using a single anticonvulsant medication such as carbamazepine (Tegretol).

• Gabapentin (Neurontin, Gabarone), baclofen and phenytoin (Dilantin, Dilantin-125) may be used as second line drugs, often in addition to carbamazepine. In many patients, as time progresses, carbamazepine becomes less effective and these drugs can be used in combination to control the pain.

• Should pain persist and medication fail to be effective, surgery or radiation therapy may be other treatment options.

• Lamotrigine (Lamictal) may be prescribed for multiple sclerosis patients who develop trigeminal neuralgia.

Non medikamentosa

• Surgery– Microvascular decompression– Gamma Knife radiosurgery

• Types of rhizotomy include: – Glycerol injection.– Balloon compression.– Radiofrequency thermal lesioning

Complementary and alternative treatments for trigeminal neuralgia include

• Acupuncture

• Biofeedback

• Vitamin therapy

• Nutritional therapy

• Electrical stimulation of nerves

New PatientCarbamazepine (CBZ)

Relief Partial Relief Alergic response orOther severe side effects

Continue CBZ

CBZ plus Phenytoin

Phenytoin oroxcarbaazepine

Reduce Slowly Relief Relief No Relief No Relief

Continue CBZ plus Phenytoin

CBZ plus Baclofen

Continue Phenytoin Baclofen

Reduce Slowly

Reduce Slowly

Relief No Relief Relief No Relief

Algoritma terapi medikamentosa trigeminal neuralgia1

Relief No Relief No Relief Relief

ContinueCBZ plus Baclofen

Reduce Slowly

Lamotrigine or

Valproic acid or

Clonazepam

ContinueBaclofen

Reduce Slowly

Surgery TricyclicAntidepresant

No Relief Relief

Continue

Algoritma terapi medikamentosa trigeminal neuralgia