Diagnostic Approach and

A Review of the Therapeutic

Options for
Trigeminal Neuralgia

PNA Headache Council 2007

 Major Areas Visited
• Cochrane Library
• AAN 2007 CPG
• IHS Library
• Books
– Adams and Victor’s Principles of Neurology
– Wolff’s Headache and other head pains
– The Headaches (Olesen et al., 2006)
• Journals = 18 papers
 Cranial Neuralgias and Central
Causes of Facial Pains (IHS)
1.Trigeminal neuralgia
2.Glossopharyngeal neuralgia
3.Nervus intermedius neuralgia
4.Superior laryngeal neuralgia
5.Nasociliary neuralgia
6.Supraorbital neuralgia
7.Other terminal branch neuralgias
8.Occipital neuralgia
 Cranial Neuralgias and Central
Causes of Facial Pains
9. Neck-tongue syndrome
10. Cold-stimulus headache
11. Constant pain caused by compression,
irritation or distortion of cranial nerves or
upper cervical roots by structural lesion
12. Optic neuritis
13. Ocular diabetic neuropathy
14. Head or facial pain attributed to herpes
zoster
Trigeminal Neuralgia (TN)
or
Tic Doloureux
 Incidence:
• There are 3-5 new cases per 100,000
people per year which is higher in
women than man at 3:2 ratio.
 Age of onset:
• For the Classical (idiopathic) form, they
are common at age 52-58 yrs old and
30-35 yrs old for the symptomatic
(secondary) forms.
 Pathophysiology
• Classical (idiopathic) form
– There is no known cause for the, however,
studies point to an underlying vascular
pathology as a cause by irritation over the
trigeminal (Gasserian) ganglion.
• Symptomatic (secondary) form,
– There are known common causes affecting
the CN V
 Pathophysiology: Symptomatic
(secondary) Form
• Compression of the trigeminal ganglion
• Demyelinating Disorder (axonal
hyperexcitability)
 Compression of the Trigeminal
Ganglion
• Vascular
– Tortous atherosclerotic branch of the
basilar artery
– Basilar artery aneurysm
• Cerebello-Pontine Angle (CPA) Mass
– Meningioma
– Chordoma
– Neurinoma
– Metastatic (nasopharyngeal Ca)
 Demyelinating Disorder #2
(axonal hyperexcitability)
• Multiple sclerosis (MS) – plaques at the
nerve root entry
• After nerve injury
– Post-trauma
– Post-dental procedure
• Post-mandibular trauma
 Demyelinating Disorder #3
(axonal hyperexcitability)
• Post-infectious
– Herpes zoster
– Tympanomastoiditis
– Dental carries (microabscesses and pulp
degeneration)
• Inflammatory
– Connective tissue disease (Sjogren’s
Disease)
Clinical Findings/Manifestations:
• The facial pain is described paroxysmal,
short, jabbing, shooting, electrical like,
lancinating, stabbing pain, “red hot needle”,
“forked lightning”
– Makes the patient wince (tic) or grimace
– Graded using the Visual Analog Scale (VAS) of
0/10 without pain to 10/10 with severe pain
• Affects the face unilaterally near the nose or
mouth (trigger points)
Clinical Findings/Manifestations:
• With no demonstrable sensory nor motor
deficits
• Attacks may be restricted to 1 or 2 divisiions
of the trigeminal nerve
– Usually involves the 2nd branch (maxillary) and/or
3rd branch (mandibular) division.
• May have trigger points on face
• May be precipitated by chewing, cold/hot
drinks, air or touch.
• Responds well to antiepileptic drugs (AED)
 Diagnostic work-up:
• Brain MRI / MRA
• Brain CT / CTA
• Audiometry
• Evoked potential studies
• Cardiac work-up
General Algorithm
FACIAL PAIN

History
Physical Examination (PE)
Neurological Examination (NE)

Diagnostic Options:
1. Brain MRI/MRA
2. Brain CT/CTA
3. Audiometry
4. Evoked potentials
5. Cardiac work-up

Clinical Symptomatic Referred

 Differential Diagnosis:
1. Demyelinating (MS)  Neurology
2. CPA tumors  Neurosurgery
3. Nasopharyngeal and Paranasal
pathology  ENT
4. Dental Pathology  Dentistry
5. Herpes zoster  Neurology
6. Classical  Medications 
Neurosurgery
7. Unstable angina  Cardiology
 Therapeutic Options
• Pharmacologic
– Antiepileptic drugs
– Non-antiepileptic drugs
• Surgical
 WP Collins et al…
• Anticonvulsant drugs have been used
in the management of pain since the
1960s and the clinical impression is
that they are useful for chronic
neuropathic pain, especially when the
pain is lancinating or burning.
The Cochrane Collaboration Database, 2006
 WP Collins et al…
• Anticonvulsants are a group of
medicines commonly used for treating
“fits” or epilepsy, but which are also
effective for treating pain.
• The type of pain which responds well is
neuropathic pain
– Postherpetic neuralgia (shingles)
– Painful complications of DM
The Cochrane Collaboration Database, 2006
 WP Collins et al…
• ACs or AEDs are effective for relieving
pain caused by damage to nerves, either
from injury or disease.
• Approximately two-thirds (2/3) of patients
who take either carbamazepine or
gabapentin can be expected to achieve
good pain relief.

The Cochrane Collaboration Database, 2006

WP Collins et al. conclusion…
• While gabapentin is increasingly being
used for neuropathic pain, the evidence
would suggest that it is not superior to
carbamazepine.

The Cochrane Collaboration Database, 2006

 Algorithm for the Medical
Management of Trigeminal Neuralgia
Clonazepam
Taper dose in 4 Sodium Valproate
weeks Lamotrigine
Oxcarbazepine

Painless for 6 With Pregabalin

weeks recurrence

Surgical Treament
Carbamazepine +
AED +/- Gabapentin

Phenytoin + Baclofen

Carbamazepine +
Baclofen

Carbamazepine Phenytoin

TN Pain
Adapted from the lecture of Dr. W. Lopez
 Pharmacologic: Antiepileptic
Drugs (AED)
• Carbamazepine
• Phenytoin
• Gabapentin
• Pregabalin
• Clonazepam
• Sodium Valproate/Divalproex
• Lamotrigine
• Oxcarbazepine
Algorithm for the Medical
Management of Trigeminal
Neuralgia (TN)
 Clonazepam
Taper dose in 4 Sodium Valproate
weeks Lamotrigine
Oxcarbazepine

Painless for 6 With Pregabalin

weeks recurrence

Surgical
Carbamazepine + Treament
AED +/- Gabapentin

Phenytoin +
Baclofen
Carbamazepine +
Baclofen

Carbamazepine Phenytoin

TN Pain
Adapted from the lecture of Dr. W. Lopez
 Pharmacologic: Non-
Antiepileptic Drugs
• Baclofen
• Tocainide
• Pimozide
• Chloripramine
• Amitriptyline
• Tizanidine
• Proparacaine
 Li He et al…

• Baclofen reduced attacks by 50-75%

• Tizanidine reduced the average attacks
per day
• Pimozide > Carbamazepine
• Chlorimipramine > Amitriptyline
• Tocainide = Carbamazepine

The Cochrane Collaboration Database, 2006

 Conclusion…
• No sufficient evidence certifies the
efficacy of non-antiepileptic drugs for
use in TN
• Baclofen, pimozide, tocainide and
chlorimipramine has the most potential
for use in TN but…
• No evidence to recommend use of
these non-antiepileptic drugs as
routine therapeutics for TN
The Cochrane Collaboration Database
Non-pharmacologic: Surgical
• Peripheral Neurectomy
– supraorbital, infraorbital and mental nerves
• Intracranial trigeminal rhizotomy
– portio major
• Glycerol gasserian gangliolysis
• Microvascular decompression
• Stereotactic radiosurgery
• Radiofrequency rhizotomy
 Algorithm for the Surgical
Management of Trigeminal Neuralgia
Surgical Treatment

Recurrence of Recurrence of
Trigeminal Trigeminal
Neuralgia Neuralgia

Medical Treatment
Algorithm for the Surgical
Management of Trigeminal
Neuralgia (TN)
 Surgical Treatment

Recurrence of Recurrence of
Trigeminal Trigeminal
Neuralgia Neuralgia

Medical Treatment
 Acknowledgement
Philippine Neurological Association
HEADACHE COUNCIL
Raquel Mallari-Alvarez
Martha Lu-Bolanos
Regina Macalintal-Canlas
Joven Cuanang
Carissa Dioquino
Thank you for
Raymond Espinosa
Ramon S. Javier
Ephrain Maranan
your kind
Philip Ramiro
Nannette Domingo-Reyes attention…
Artemio Roxas Jr
Amado San Luis
Socorro Florendo-Sarfati
Chair: Servando T. Liban II