Transcript Trigeminal Neuralgia Trigeminal neuralgia

PAIN AND ITS MANAGEMENT IN
TRIGEMINAL NEURALGIA
CANCER
By
Sakhawat Rehman
Department Of Pharmacology and Toxicology
Trigeminal Neuralgia
Trigeminal neuralgia (TN), is a chronic
pain condition that affects the trigeminal
or 5th cranial nerve, one of the most
widely distributed nerves in the head.
TN is a form of neuropathic pain
2 Types
Type 1" or TN1)
Type 2" or TN2),
Trigeminal Nerve
The trigeminal nerve is one of 12 pairs of
nerves that are attached to the brain. The
nerve has three branches that conduct
sensations from the upper, middle, and
lower portions of the face, as well as the
oral cavity, to the brain.
Branches
ophthalmic, or upper, branch
The maxillary, or middle, branch
The mandibular, or lower, branch
What causes trigeminal neuralgia?
Blood vessel pressing
on the trigeminal nerve.
Sclerosis,
Tumours
Physical Injury
Although there is general agreement that none of the many existing
theories fully explain all known characteristics of TGN pain
More specifically, the existing evidence suggests that a
slowly evolving process, whether a compression exerted
on the nerve by a blood vessel or tumour or alteration
of neural functions by an plaque at the level of the
dorsal root entry zone, leads to increased excitability in
some of the trigeminal afferents and subsequently to
typical TGN.
symptoms of trigeminal neuralgia
Pain varies, depending on the type of TN,
and may range from sudden, severe, and
stabbing to a more constant, aching, burning
sensation.
The intense flashes of pain can be triggered
by vibration or contact with the cheek
The pain may affect a small area of the face
or may spread.
How is TN diagnosed?
Clinical Signs
Special MRI imaging
Differential diagnosis of TGN. *SUNCT, Short‐lasting, unilateral, neuralgiform headcahe with
conjunctival injection and tearing; **CPH, chronic paroxysmal hemicrania.
Condition
Location of pain
Duration of pain or
attack
Shooting pain or
paroxysms
Cluster headache
Retrobulbar, cheek,
chin
20 min to hours
Only superimposed on
Prominent
deep dull pain
SUNCT*
Forehead, retrobulbar
5 s to several minutes
Yes
Autonomic symptoms
Prominent
Pain relief with
carbamazepine
Comments
Slight
Triptans help Alcohol
provokes
None
Almost exclusively
inwomen; rare
CPH**
Forehead, retrobulbar
2–45 min
No
Prominent
None
Responsive to
indomethacin
Cracked tooth
syndrome
Upper jaw lower jaw
Seconds
Yes
None
None
Provoked on biting and
chewing
Jabs and jolts
syndrome
Anywhere in the head Seconds
Yes
None
Good
No precipitating factors
Continuous
Superimposed
background pain
Variable, mild
History of shingles
Tactile
allodynia,Sensory
Variable, usually modes impairment
Continuous
None
None
None
Forehead, eye, cheek
Post‐herpetic neuralgia (rarely)
Giant cell arteritis
Forehead, neck,
temple
Jaw claudication
Distinguishing Features Between Trigeminal Neuralgia and Atypical Facial Pain
Trigeminal
Neuralgia
Feature
Atypical Facial Pain
Prevalence
Rare
Common
Main location
Trigeminal area
Face, neck, ear
Pain duration
Seconds to 2 minutes
Hours to days
Character
Electric jerks, stabbing
Throbbing, dull
Pain intensity
Severe
Mild to moderate
Provoking factors
Light touch, washing,
shaving, eating, talking
Stress, cold
Associated symptoms
None
Sensory abnormalities
Treatment
Treatment options include medicines, surgery, and complementary approaches.
Drug
Initial dose
Maintenance dose
Carbamazepine
200 mg/ day
400–1200 mg /day
Oxcarbazepine
300 mg /day
600–1200 mg /day
Phenytoin
300 mg
200–400 mg
Lamotrigine
25–50 mg
200–400 mg
Baclofen
10 mg
30–80 mg
Surgery
Rhizotomy
Neurectomy
Complementary approaches
Some
individuals
manage
trigeminal
neuralgia
using
complementary techniques, usually in combination with drug
treatment.
Yoga
creative visualization
aroma therapy
Acupuncture
vitamin therapy
nutritional therapy.
We can’t rely
purely on
complementary
medicine but it
requires
combination…
Cancer
Benign Tumour
Malignant Tumour
Pain in cancer
Pain
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described
in terms of such damage.
Acute
chronic
Nociceptive
Neuropathic
Causes of Pain in Cancer
Tumor-related
Tumors cause pain by crushing or infiltrating tissue, triggering infection or inflammation, or releasing
chemicals that make normally non-painful stimuli painful..
Treatment-related
Potentially painful cancer treatments include
Immunotherapy which may produce joint
or muscle pain;
Radiotherapy, which can cause skin
reactions, enteritis, fibrosis, myelopathy,
bone necrosis, neuropathy.
Chemotherapy, often associated
mucositis, joint pain, muscle
peripheral neuropathy.
with
pain,
Infection
Pathophysiology
Cancer pain shares the same
neurophysiologic pathway as
non-cancer pain. This process of
nociception involves activation of
the
sensory
afferents
by
persistent
noxious
stimuli,
transduction,
transmission,
modulation, and perception.
Guidelines for a correct assessment of the patient with pain
1. Assess and re-assess the pain
• Causes, onset, type, site, duration, intensity, relief and temporal patterns of the pain
• Presence of the trigger factors and the signs and symptoms associated with the pain
• Use of analgesics and their efficacy and tolerability
2. Assess and re-assess the patient
• The clinical situation by means of a complete/specific physical examination and the specific radiological and/or biochemical investigations
• The presence of interference of pain with the patient's daily activities, work, social life, sleep patterns, appetite, sexual functioning and mood
• The impact of the disease and the therapy on the physical, psychological and social conditions
• The presence of a caregiver, the psychological status, the degree of awareness of the disease, anxiety and depression and suicidal ideation,
his/her social environment, quality of life, spiritual concerns/needs
• The presence and intensity of signs, physical and/or emotional symptoms associated with cancer pain syndromes
• The functional status
• The presence of opiophobia
3. Assess and re-assess your ability to inform and to communicate with the patient and the family
• Take time to spend with the patient and the family to understand their needs
Validated and most frequently used pain assessment tools.
Ripamonti C I et al. Ann Oncol 2011;22:vi69-vi77
Management
Psychological Coping strategies
Psychosocial interventions
Medications
WHO's cancer pain ladder for Pain
Management
Management of cancer pain:
WHO:
Step 1…
Substance
Widely available forms and
strengths
Time to onset (min)
Caution
Maximal daily dose
Acetaminophen
(paracetamol)
Tablets, suppositories 500–
1000 mg
15–30
Hepatotoxicity
4 × 1000 mg
Acetylsalycic acid
Tablets 500–1000 mg
15–30
GI toxicity, allergy, platelet
inhibition
3 × 1000 mg
Ibuprofen
Tablets 200–400–600 mg;
tablets 800 mg modified
release; topical gels
15–30; 120+
GI and renal toxicity
4 × 600 mg; 3× 800 mg
modified release
Ketoprofen
Tablets 25–75 mg; tablets
100–150–200 mg modified
release
30+
GI and renal toxicity
4 × 75 mg; 2 × 200 mg
Diclofenac
Tablets 25–50–75 mg; tablets
30–120
100 mg modified release
GI and renal toxicity
4 × 50 mg; 2 × 100 mg
Mefenamic acid
Capsules 250–500 mg
30+
GI and renal toxicity
4 × 500 mg
Naproxen
Tablets 250–375–500 mg
30+
GI and renal toxicity
2 × 500 mg
Comparison of selected opioids for mild to moderate pain
(WHO step II)
Substance
Relative effectiveness
Widely available forms
compared with oral
and strengths
morphine
Duration of
effectiveness (h)
Maximal daily dose
Starting dose without
pretreatment
Dihydrocodeine
Modified-release
tablets 60–90–120 mg
12
240 mg
60–120 mg
Codeine
Tablet 15–30–60 mg
4–6
360 mg
15–60 mg
2–4
400 mg
50–100 mg
12
400 mg
50–100 mg
Drops 100 mg/ml;
capsules 50 mg
0.17
0.1–0.2
Tramadol
Modified-release
0.1–0.2
tablets 100–150–200 mg
Comparison of selected opioids for moderate to severe pain
(WHO step III)
Substance
Route
Relative effectiveness compared
Maximal daily dose
with oral morphinea
Starting dose without
pretreatment
Morphine sulfate
Oral
1
No upper limitb
20–40 mg
Morphine
i.v.
3
No upper limitb
5–10 mg
Oxycodone
Oral
1.5–2
No upper limitb
20 mg
Hydromorphone
Oral
7.5
No upper limitb
8 mg
Fentanyl transdermal
TTS
+ 4c
No upper limitb
12 μg/hd
Buprenorphine
Oral
75
4 mg
0.4 mg
Buprenorphine
i.v.
100
3 mg
0.3–0.6 mg
Buprenorphine transdermal
TTS
+ 4c
140 μg/h
17.5–35μg/h
Methadone
Oral
4–8–12e
No upper limitb
10 mg
Nicomorphine
Oral
1
20 mg
5 mg
Nicomorphine
i.v.
3
20 mg
5 mg
Selected adjuvant drugs for neuropathic pain
Substance
Widely available forms and
strengths (mg)
Activity
Sedation
Range of daily doses (mg)
Amitryptiline
Tablets 25–50
Antidepressive
+++
50–200
Clomipramine
Tablets 10–75
Antidepressive
(+)
50–200
Nortriptyline
Tablets 10–25
Antidepressive
+
50–225
Fluoxetine
Tablets 20
Antidepressive
+
20–80
Duloxetine
Tablets 30–60
Antidepressive
+
60–120
Carbamazepine
Tablets 200–400
Antiepileptic
+
400–1600
Gabapentin
Tablets 200–300–400–800
Antiepileptic
++
900–3600
Pregabalin
Tablets 25–50–75–100–150–
200–300 mg
Antiepileptic
+
150–600
Haloperidol
Drops, tablets, vials
Neuroleptic
+
3–20
Chlorpromazine
Drops, tablets, suppositories,
vials
Neuroleptic
+
25–200

Usually the lowest doses of antidepressants and neuroleptics are sufficient as an adjunct to opioids
unless severe depression or major psychosis has to be treated with higher doses as appropriate.
Radiation
Radiotherapy is used when drug treatment
is failing to control the pain of a growing
tumor, such as in bone metastisis
Radiopharmaceuticals that target specific
tumors have been used to treat the pain of
metastatic illnesses. Relief may occur
within a week of treatment and may last
from two to four months.
Neurolytic block
Cutting or destruction of nervous tissue
Patient-controlled analgesia
Intrathecal pump
An intrathecal pump infuses an opioid such as morphine directly into the fluid-filled space (the
subarachnoid cavity) between the spinal cord and its protective sheath, providing enhanced
analgesia with reduced systemic side effects.
Long-term epidural catheter
The outer layer of the sheath surrounding the spinal cord is called the dura mater. Between
this and the surrounding vertebrae is the epidural space, filled with connective tissue, fat and
blood vessels, and crossed by the spinal nerve roots. A long-term epidural catheter may be
inserted into this space for three to six months, to deliver anesthetics or analgesics. The line
carrying the drug may be threaded under the skin to emerge at the front of the patient, a
process called "tunneling", recommended with long-term use to reduce the chance of any
infection at the exit site reaching the epidural space.
Spinal cord stimulation
Deep brain stimulation
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