Transcript A Review of the Diagnostic and Therapeutic Management

Diagnostic Approach and
A Review of the Therapeutic
Options for
Trigeminal Neuralgia
PNA Headache Council 2007
Major Areas Visited
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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:
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Brain MRI / MRA
Brain CT / CTA
Audiometry
Evoked potential studies
Cardiac work-up
General Algorithm
FACIAL PAIN
History
Physical Examination (PE)
Neurological Examination (NE)
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Clinical
Diagnostic Options:
Brain MRI/MRA
Brain CT/CTA
Audiometry
Evoked potentials
Cardiac work-up
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
Sodium Valproate
Lamotrigine
Oxcarbazepine
Taper dose in 4
weeks
Painless for 6
weeks
Pregabalin
With
recurrence
Surgical Treament
AED +/-
Carbamazepine +
Gabapentin
Phenytoin + Baclofen
Carbamazepine +
Baclofen
Carbamazepine
Phenytoin
TN Pain
Adapted from the lecture of Dr. W. Lopez
Pharmacologic: Antiepileptic
Drugs (AED)
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Carbamazepine
Phenytoin
Gabapentin
Pregabalin
Clonazepam
Sodium Valproate/Divalproex
Lamotrigine
Oxcarbazepine
Algorithm for the Medical
Management of Trigeminal
Neuralgia (TN)
Clonazepam
Sodium Valproate
Lamotrigine
Oxcarbazepine
Taper dose in
4 weeks
Painless for
6 weeks
With
recurrence
AED +/-
Pregabalin
Surgical
Treament
Carbamazepine
+ Gabapentin
Phenytoin +
Baclofen
Carbamazepine
+ Baclofen
Carbamazepine
TN Pain
Phenytoin
Adapted from the lecture of Dr. W. Lopez
Pharmacologic: NonAntiepileptic Drugs
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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
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Glycerol gasserian gangliolysis
Microvascular decompression
Stereotactic radiosurgery
Radiofrequency rhizotomy
Algorithm for the Surgical
Management of Trigeminal Neuralgia
Surgical Treatment
Recurrence of
Trigeminal
Neuralgia
Recurrence of
Trigeminal
Neuralgia
Medical Treatment
Acknowledgement
Philippine Neurological Association
HEADACHE COUNCIL
Raquel Mallari-Alvarez
Martha Lu-Bolanos
Regina Macalintal-Canlas
Joven Cuanang
Carissa Dioquino
Raymond Espinosa
Ramon S. Javier
Ephrain Maranan
Philip Ramiro
Nannette Domingo-Reyes
Artemio Roxas Jr
Amado San Luis
Socorro Florendo-Sarfati
Chair: Servando T. Liban II
Thank you
for your kind
attention…