Diagnostic Approach and Diagnostic Approach and A Review of the Therapeutic A Review of the Therapeutic

Options for Options for Trigeminal NeuralgiaTrigeminal Neuralgia

PNA Headache Council 2007PNA Headache Council 2007

Major Areas VisitedMajor Areas Visited

• Cochrane LibraryCochrane Library

• AAN 2007 CPGAAN 2007 CPG

• IHS LibraryIHS Library

• BooksBooks– Adams and Victor’s Principles of NeurologyAdams and Victor’s Principles of Neurology– Wolff’s Headache and other head painsWolff’s Headache and other head pains– The Headaches (Olesen et al., 2006)The Headaches (Olesen et al., 2006)

• Journals = 18 papersJournals = 18 papers

Cranial Neuralgias and Central Cranial Neuralgias and Central Causes of Facial Pains (IHS)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 Cranial Neuralgias and Central Causes of Facial PainsCauses of Facial Pains

9. Neck-tongue syndrome10.Cold-stimulus headache11.Constant pain caused by compression,

irritation or distortion of cranial nerves or upper cervical roots by structural lesion

12.Optic neuritis13.Ocular diabetic neuropathy14.Head or facial pain attributed to herpes

zoster

Trigeminal Neuralgia (TN) Trigeminal Neuralgia (TN) or or

Tic DoloureuxTic Doloureux

Incidence:Incidence:

• There are 3-5 new cases per 100,000 There are 3-5 new cases per 100,000 people per year which is higher in people per year which is higher in women than man at 3:2 ratio.women than man at 3:2 ratio.

Age of onset:Age of onset:

• For the Classical (idiopathic) form, they For the Classical (idiopathic) form, they are common at age 52-58 yrs old and are common at age 52-58 yrs old and 30-35 yrs old for the symptomatic 30-35 yrs old for the symptomatic (secondary) forms.(secondary) forms.

PathophysiologyPathophysiology

• Classical (idiopathic) form Classical (idiopathic) form – There is no known cause for the, however, There is no known cause for the, however,

studies point to an underlying vascular studies point to an underlying vascular pathology as a cause by irritation over the pathology as a cause by irritation over the trigeminal (Gasserian) ganglion. trigeminal (Gasserian) ganglion.

• Symptomatic (secondary) form, Symptomatic (secondary) form, – There are known common causes affecting There are known common causes affecting

the CN Vthe CN V

Pathophysiology: Symptomatic Pathophysiology: Symptomatic (secondary) Form(secondary) Form

• Compression of the trigeminal ganglionCompression of the trigeminal ganglion

• Demyelinating Disorder (axonal Demyelinating Disorder (axonal hyperexcitability)hyperexcitability)

Compression of the Trigeminal Compression of the Trigeminal Ganglion Ganglion

• VascularVascular– Tortous atherosclerotic branch of the Tortous atherosclerotic branch of the

basilar arterybasilar artery– Basilar artery aneurysm Basilar artery aneurysm

• Cerebello-Pontine Angle (CPA) MassCerebello-Pontine Angle (CPA) Mass– MeningiomaMeningioma– ChordomaChordoma– Neurinoma Neurinoma – Metastatic (nasopharyngeal Ca) Metastatic (nasopharyngeal Ca)

Demyelinating Disorder #2Demyelinating Disorder #2(axonal hyperexcitability)(axonal hyperexcitability)

• Multiple sclerosis (MS) – plaques at the Multiple sclerosis (MS) – plaques at the nerve root entrynerve root entry

• After nerve injuryAfter nerve injury– Post-trauma Post-trauma – Post-dental procedurePost-dental procedure

• Post-mandibular traumaPost-mandibular trauma

Demyelinating Disorder #3Demyelinating Disorder #3(axonal hyperexcitability)(axonal hyperexcitability)

• Post-infectiousPost-infectious– Herpes zosterHerpes zoster– TympanomastoiditisTympanomastoiditis– Dental carries (microabscesses and pulp Dental carries (microabscesses and pulp

degeneration)degeneration)

• InflammatoryInflammatory– Connective tissue disease (Sjogren’s Connective tissue disease (Sjogren’s

Disease)Disease)

Clinical Findings/Manifestations:Clinical Findings/Manifestations:

• The facial pain is described paroxysmal, The facial pain is described paroxysmal, short, jabbing, shooting, electrical like, short, jabbing, shooting, electrical like, lancinating, stabbing pain, “red hot needle”, lancinating, stabbing pain, “red hot needle”, “forked lightning”“forked lightning”– Makes the patient wince (tic) or grimaceMakes the patient wince (tic) or grimace– Graded using the Visual Analog Scale (VAS) of Graded using the Visual Analog Scale (VAS) of

0/10 without pain to 10/10 with severe pain0/10 without pain to 10/10 with severe pain

• Affects the face unilaterally near the nose or Affects the face unilaterally near the nose or mouth (trigger points)mouth (trigger points)

Clinical Findings/Manifestations:Clinical Findings/Manifestations:

• With no demonstrable sensory nor motor With no demonstrable sensory nor motor deficits deficits

• Attacks may be restricted to 1 or 2 divisiions Attacks may be restricted to 1 or 2 divisiions of the trigeminal nerveof the trigeminal nerve– Usually involves the 2Usually involves the 2ndnd branch (maxillary) and/or branch (maxillary) and/or

33rdrd branch (mandibular) division. branch (mandibular) division.

• May have trigger points on faceMay have trigger points on face• May be precipitated by chewing, cold/hot May be precipitated by chewing, cold/hot

drinks, air or touch.drinks, air or touch.• Responds well to antiepileptic drugs (AED)Responds well to antiepileptic drugs (AED)

Diagnostic work-up:Diagnostic work-up:

• Brain MRI / MRABrain MRI / MRA

• Brain CT / CTABrain CT / CTA

• AudiometryAudiometry

• Evoked potential studiesEvoked potential studies

• Cardiac work-upCardiac work-up

General AlgorithmFACIAL PAINFACIAL PAIN

HistoryHistoryPhysical Examination (PE)Physical Examination (PE)

Neurological Examination (NE)Neurological Examination (NE)

Diagnostic Options:Diagnostic Options:1.1. Brain MRI/MRABrain MRI/MRA2.2. Brain CT/CTABrain CT/CTA3.3. AudiometryAudiometry4.4. Evoked potentialsEvoked potentials5.5. Cardiac work-upCardiac work-up

ClinicalClinical SymptomaticSymptomatic ReferredReferred

Differential Diagnosis: Differential Diagnosis:

1.1. Demyelinating (MS) Demyelinating (MS) Neurology Neurology

2.2. CPA tumors CPA tumors Neurosurgery Neurosurgery

3.3. Nasopharyngeal and Paranasal Nasopharyngeal and Paranasal pathology pathology ENT ENT

4.4. Dental Pathology Dental Pathology Dentistry Dentistry

5.5. Herpes zoster Herpes zoster Neurology Neurology

6.6. Classical Classical Medications Medications Neurosurgery Neurosurgery

7.7. Unstable angina Unstable angina Cardiology Cardiology

Therapeutic OptionsTherapeutic Options

• PharmacologicPharmacologic– Antiepileptic drugsAntiepileptic drugs– Non-antiepileptic drugsNon-antiepileptic drugs

• SurgicalSurgical

WP Collins et al…WP Collins et al…

• Anticonvulsant drugs have been used Anticonvulsant drugs have been used in the management of pain since the in the management of pain since the 1960s and the clinical impression is 1960s and the clinical impression is that they are useful for chronic that they are useful for chronic neuropathic pain, especially when the neuropathic pain, especially when the pain is lancinating or burning.pain is lancinating or burning.

The Cochrane Collaboration Database, 2006The Cochrane Collaboration Database, 2006

WP Collins et al…WP Collins et al…

• Anticonvulsants are a group of Anticonvulsants are a group of medicines commonly used for treating medicines commonly used for treating “fits” or epilepsy, but which are also “fits” or epilepsy, but which are also effective for treating pain. effective for treating pain.

• The type of pain which responds well is The type of pain which responds well is neuropathic painneuropathic pain– Postherpetic neuralgia (shingles)Postherpetic neuralgia (shingles)– Painful complications of DMPainful complications of DM

The Cochrane Collaboration Database, 2006The Cochrane Collaboration Database, 2006

WP Collins et al…WP Collins et al…

• ACs or AEDs are effective for relieving ACs or AEDs are effective for relieving pain caused by damage to nerves, pain caused by damage to nerves, either from injury or disease.either from injury or disease.

• Approximately two-thirds (2/3) of Approximately two-thirds (2/3) of patients who take either carbamazepine patients who take either carbamazepine or gabapentin can be expected to or gabapentin can be expected to achieve good pain relief.achieve good pain relief.

The Cochrane Collaboration Database, 2006The Cochrane Collaboration Database, 2006

WP Collins et al. conclusion…WP Collins et al. conclusion…

• While gabapentin is increasingly being While gabapentin is increasingly being used for neuropathic pain, the evidence used for neuropathic pain, the evidence would suggest that it is not superior to would suggest that it is not superior to carbamazepine.carbamazepine.

The Cochrane Collaboration Database, 2006The Cochrane Collaboration Database, 2006

Algorithm for the Medical Algorithm for the Medical Management of Trigeminal Neuralgia Management of Trigeminal Neuralgia

TN PainTN Pain

Carbamazepine + Carbamazepine + BaclofenBaclofen

CarbamazepineCarbamazepine

PregabalinPregabalin

Carbamazepine + Carbamazepine + GabapentinGabapentin

PhenytoinPhenytoin

Phenytoin + BaclofenPhenytoin + Baclofen

ClonazepamClonazepamSodium ValproateSodium Valproate

LamotrigineLamotrigineOxcarbazepineOxcarbazepine

Adapted from the lecture of Dr. W. Lopez

Surgical Surgical TreamentTreament

AED +/-AED +/-

Painless for 6 Painless for 6 weeksweeks

Taper dose in 4 Taper dose in 4 weeksweeks

With With recurrencerecurrence

Pharmacologic: Antiepileptic Pharmacologic: Antiepileptic Drugs (AED)Drugs (AED)

• CarbamazepineCarbamazepine• PhenytoinPhenytoin• GabapentinGabapentin• PregabalinPregabalin• ClonazepamClonazepam• Sodium Valproate/DivalproexSodium Valproate/Divalproex• LamotrigineLamotrigine• OxcarbazepineOxcarbazepine

Algorithm for the Medical Algorithm for the Medical Management of Trigeminal Management of Trigeminal

Neuralgia (TN)Neuralgia (TN)

TN PainTN Pain

Carbamazepine Carbamazepine + Baclofen+ Baclofen

CarbamazepineCarbamazepine

PregabalinPregabalin

Carbamazepine Carbamazepine + Gabapentin+ Gabapentin

PhenytoinPhenytoin

Phenytoin + Phenytoin + BaclofenBaclofen

ClonazepamClonazepamSodium ValproateSodium Valproate

LamotrigineLamotrigineOxcarbazepineOxcarbazepine

Adapted from the lecture of Dr. W. Lopez

Surgical Surgical TreamentTreament

AED +/-AED +/-

Painless for Painless for 6 weeks6 weeks

Taper dose in Taper dose in 4 weeks4 weeks

With With recurrencerecurrence

Pharmacologic: Non-Pharmacologic: Non-Antiepileptic DrugsAntiepileptic Drugs

• BaclofenBaclofen

• TocainideTocainide

• PimozidePimozide

• ChloripramineChloripramine

• AmitriptylineAmitriptyline

• TizanidineTizanidine

• ProparacaineProparacaine

Li He et al…Li He et al…

• Baclofen reduced attacks by 50-75%Baclofen reduced attacks by 50-75%• Tizanidine reduced the average attacks Tizanidine reduced the average attacks

per day per day • Pimozide > CarbamazepinePimozide > Carbamazepine• Chlorimipramine > AmitriptylineChlorimipramine > Amitriptyline• Tocainide = CarbamazepineTocainide = Carbamazepine

The Cochrane Collaboration Database, 2006The Cochrane Collaboration Database, 2006

Conclusion…Conclusion…

• No sufficient evidence certifies the No sufficient evidence certifies the efficacy of non-antiepileptic drugs for efficacy of non-antiepileptic drugs for use in TNuse in TN

• Baclofen, pimozide, tocainide and Baclofen, pimozide, tocainide and chlorimipramine has the most potential chlorimipramine has the most potential for use in TN but… for use in TN but…

• No evidence to recommend use of No evidence to recommend use of these non-antiepileptic drugs as these non-antiepileptic drugs as routine therapeutics for TNroutine therapeutics for TN

The Cochrane Collaboration The Cochrane Collaboration DatabaseDatabase

Non-pharmacologic: SurgicalNon-pharmacologic: Surgical

• Peripheral NeurectomyPeripheral Neurectomy– supraorbital, infraorbital and mental supraorbital, infraorbital and mental

nervesnerves

• Intracranial trigeminal rhizotomyIntracranial trigeminal rhizotomy– portio majorportio major

• Glycerol gasserian gangliolysisGlycerol gasserian gangliolysis

• Microvascular decompressionMicrovascular decompression

• Stereotactic radiosurgeryStereotactic radiosurgery

• Radiofrequency rhizotomyRadiofrequency rhizotomy

Algorithm for the Surgical Algorithm for the Surgical Management of Trigeminal Neuralgia Management of Trigeminal Neuralgia

Recurrence of Trigeminal Neuralgia

Recurrence of Trigeminal Neuralgia

Medical Treatment

Surgical Treatment

Acknowledgement Acknowledgement Philippine Neurological AssociationPhilippine Neurological Association

HEADACHE COUNCIL

Raquel Mallari-AlvarezRaquel Mallari-Alvarez

Martha Lu-Bolanos Martha Lu-Bolanos

Regina Macalintal-CanlasRegina Macalintal-Canlas

Joven CuanangJoven Cuanang

Carissa Dioquino Carissa Dioquino

Raymond Espinosa Raymond Espinosa

Ramon S. JavierRamon S. Javier

Ephrain MarananEphrain Maranan

Philip Ramiro Philip Ramiro

Nannette Domingo-ReyesNannette Domingo-Reyes

Artemio Roxas JrArtemio Roxas Jr

Amado San LuisAmado San Luis

Socorro Florendo-SarfatiSocorro Florendo-Sarfati

Chair: Servando T. Liban IIChair: Servando T. Liban II

Thank you Thank you for your kind for your kind attention…attention…