B.

Wayne Blount, MD, MPH

Tic Doloureau
4.3 per 100,000
Slight female predominance : 1.74

t0 1
Peak incidence 60-70 y.o.
Unusual before age 40
No racial prediliction

Tic Doloureau
Higher incidence with M.S. &

HTN
Spontaneous remission possible,

BUT unusual
Most patients will have episodic

attacks over many years

Now 2 Types Are

Identified
Classical
Symptomatic

Classical Criteria
A. Paroxysmal attacks of pain lasting

from a fraction of a second to 2

minutes, affecting 1 or more divisions
of the trigeminal nerve, & fulfilling
criteria B & C.
B. Pain has at least 1 of the following
characteristics:
1. Intense, sharp, superficial, or stabbing
Precipitated from trigger zones or by

trigger factors

Classical Criteria
C. Attacks are stereotyped in

the individual patient

D. No clinically evident neuro deficit
E. Not attributed to another disorder.

Symptomatic Criteria
A. Paroxysmal attacks of pain lasting

from a fraction of a second to 2

minutes, with or w/o persistence of
pain between paroxysms, affecting 1
or more divisions of the trigeminal
nerve, & fulfilling criteria B & C.
B. . Pain has at least 1 of the following
characteristics:
1. Intense, sharp, superficial, or stabbing
Precipitated from trigger zones or by

trigger factors

Symptomatic Criteria
C. Attacks are stereotyped

in the individual patient

D. A causative lesion, other than

vascular compression, has been

demonstrated by special
investigations &/or posterior fossa
exploration.

Pathophysiology

? Pathophysiology ?
Demyelination of the trigeminal nerve,

causing ectopic impulses and then

ephaptic conduction
Vascular compression of the nerve root by
aberrant or tortuous vessels
Compression by tumor
Amyloid
A-V malformation
Pons Infarct
Bony compression

Diagnosis
Clinical
Consider in all patients with

unilateral facial pain

Prompt Dx important as pain can be
severe
Distinguish classical from
symptomatic for RX purposes
Look for red flags of other diseases

Red Flags
Abnormal Neuro exam
Abnormal oral, dental, or ear exam
Age < 40 yrs
Bilateral SXs
Dizziness or vertigo

Red Flags
Hearing loss
Numbness
Pain lasting > 2 minutes
Pain outside of trigeminal distribution
Visual changes

Diagnostic History
Very important
Recurrent, unilateral facial pain
Lasts seconds
May recur 100s of times per day
Pain :
Severe
Sharp
Superficial

Stereotypical
Stabbing
Shock-like

Diagnostic History
1 or more of the nerves divisions
Trigger factors:

Talking
Smiling
Chewing
Teeth brushing

Shaving
Applying make-up
Wind

Age > 40 yrs.

Ask about other neuro Sx
Asymptomatic time or not ?

Physical Exam
Usually a normal exam
Useful for identifying abnormals that

point to other DXs

HEENT, including TMJ & Masseter
Oral exam, including teeth & gums
Neuro exam
Check for trigger zones

Diagnostic Testing
Generally Not helpful
MRI is the Test of Choice : C Rec
? Trigeminal reflex testing? Unclear

usefulness & I would NOT do it

Differential List
Cluster HA Dental Pain
Giant Cell Arteritis
Migraine
Glossopharyngeal
Neuralgia Otitis Media
Intracranial Tumor
Multiple Sclerosis

Sinusitis
TMJ Syndrome
Postherpetic Neuralgia
Paroxysmal
Hemicrania

Treatment
Medical
Surgical
No Behavioral, unless it becomes a

cause of Chronic Pain

Medical Treatment
Carbamazepine : A Rec
NNT = 2.5 (For trigeminal Neuralgia)
NNH = 3.7 (For all diseases)
Some suggest it as a diagnostic trial
Doses range from 100 to 2,400 mg per

day
Most respond to 200 to 800 mg per day
Immediate release (lasts about 6 hrs.)
Extended release (lasts about 12 hrs.)

Medical Treatment
Carbamazepine Should be the initial

Rx of choice for classical Trigeminal

Neuralgia
If get no or only partial response to

carbamazepine, add or substitute

another pharmacologic agent:

Medical Treatment
Other agents to try : ( Not listed in any

order)
Baclofen : 10 m- 80 mg daily
Dilantin
Lamictal
Neurontin
Topamax
Klonopin
Orap
Depakene

Medical Treatment
A recent Cochrane review said there

was insufficient evidence to show

benefit from non-epileptic agents in
trigeminal neuralgia

Follow-up
Achieve balance between pain and

med side effects

Most want complete remission, which
is possible and warranted
Can try a trial sans meds after
several months symptom free
(Think 4-6)

Surgical Treatment
After failure of Pharm agents
Unusual
Recurrences occur for many
Both percutaneous & open techniques
Glycerol injection Ballon Compression
Radio Rhizotomy Gamma knife
Partial RhizotomyMicrovascular

decompression

Summary
2 Types of trigeminal neuralgia
A clinical DX
Everyone gets a head & face

MRI
Carbamazepine is the
treatment of choice.

References
Kraft, RM. Trigeminal Neuralgia.

AFP. 2008;77:1291-1296.
Cochrane Collaboration
Haanpaa M, et al. Neuropathic
Facial Pain. Suppl Clin
Neurophysiol. 2006;58:153-170.

References
Cruccu G, et al. Diagnosis of

trigeminal neuralgia. In: Cruccu G, et

al. Brainstem Function &
Dysfunction. Amsterdam: Elsevier;
2006:171-186.
Wayne Blount