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Trigeminal neuralgia

Specialties > General practice

Background knowledge 🧠

Definition

  • Trigeminal neuralgia is a chronic pain condition affecting the trigeminal nerve, characterized by sudden, severe facial pain.
  • Typically presents as unilateral, brief, sharp, or electric shock-like pain in the distribution of one or more branches of the trigeminal nerve.
  • Also known as tic douloureux.

Epidemiology

  • More common in females than males.
  • Typically presents in individuals over 50 years old.
  • Annual incidence: 4–13 per 100,000.
  • Higher prevalence in individuals with multiple sclerosis.

Aetiology and Pathophysiology

  • Most commonly due to compression of the trigeminal nerve root by an aberrant loop of an artery or vein.
  • Can be associated with demyelinating diseases like multiple sclerosis.
  • Rarely caused by space-occupying lesions or infections.
  • Leads to focal demyelination and hyperexcitability of the nerve fibers.
  • Secondary trigeminal neuralgia involves identifiable neurological deficits or imaging abnormalities.

Types

  • Type 1: Classical trigeminal neuralgia with purely paroxysmal pain.
  • Type 2: Trigeminal neuralgia with continuous background pain.
  • Secondary trigeminal neuralgia: Caused by an underlying structural lesion or disease.
  • Atypical trigeminal neuralgia: Less well-defined, often with overlapping features.

Clinical Features 🌡️

Symptoms

  • Sudden, severe, stabbing or electric shock-like pain.
  • Pain triggered by touch, chewing, talking, or brushing teeth.
  • Typically unilateral, affecting the maxillary (V2) or mandibular (V3) divisions of the trigeminal nerve.
  • Episodes last from seconds to minutes, with periods of remission.
  • Can be associated with background aching or burning pain in some cases.
  • Absence of sensory loss in classical trigeminal neuralgia.

Signs

  • Usually no objective signs on examination.
  • May observe facial muscle spasms during painful episodes (tic douloureux).
  • In secondary trigeminal neuralgia, neurological deficits (e.g., sensory loss) may be present.
  • Careful neurological examination is essential to exclude secondary causes.

Investigations 🧪

Tests

  • Diagnosis is primarily clinical, based on history and examination.
  • MRI with contrast to rule out secondary causes (e.g., tumor, multiple sclerosis).
  • Magnetic resonance angiography (MRA) may identify vascular compression.
  • Trigeminal reflex testing may be used in research settings.
  • Blood tests are typically normal but may be conducted to rule out other conditions.

Management 🥼

Management

  • First-line treatment: Carbamazepine or oxcarbazepine.
  • Second-line treatment: Lamotrigine, gabapentin, or baclofen.
  • Surgical options: Microvascular decompression, percutaneous balloon compression, or gamma knife radiosurgery.
  • Botulinum toxin injections may be considered in refractory cases.
  • Psychological support and pain management are important in chronic cases.

Complications

  • Medication side effects (e.g., drowsiness, dizziness).
  • Psychological impact: Depression, anxiety.
  • Potential for nerve damage following surgical interventions.
  • Pain recurrence despite treatment.

Prognosis

  • Varies depending on the cause and treatment.
  • Classical trigeminal neuralgia has a good prognosis with appropriate treatment.
  • Some patients experience remission, while others may have recurrent episodes.
  • Prognosis is poorer in secondary trigeminal neuralgia.

Key Points

  • Trigeminal neuralgia is a severe, chronic pain disorder affecting the trigeminal nerve.
  • Diagnosis is primarily clinical, with MRI used to exclude secondary causes.
  • Carbamazepine is the first-line treatment, with surgical options available for refractory cases.
  • Psychological support is essential for managing the chronic nature of the condition.

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General practice