Trigeminal neuralgia
multidisciplinary approach
Prof Joanna Zakrzewska Eastman Dental Hospital
Aims and Objectives
Trigeminal Neuralgia
Classification
Diagnosis
Art of Listening
Surgical Medical Psychological
Trigeminal Neuralgia –IASP
a sudden, usually
unilateral, severe,
brief, stabbing,
recurrent pain in
the distribution of
one or more
branches of the
fifth cranial nerve.
Misery by Rosa Sepple
Classification of head and face pain
2013
ICHD 2013
13.1.1 Classical trigeminal neuralgia
13.1.1.2 Classical trigeminal neuralgia with
concomitant persistent facial pain
Previously used terms:
Atypical trigeminal neuralgia; trigeminal
neuralgia, type 2.
Chapter 13
Age and gender patterns of TN
pain
DO NOT Resemble :
TMD
Migraine
Tension type headache
Irritable bowel syndrome
DO resemble:
Cancer
Heart disease
Other degenerative disorders
Associations
TN positively associated
hypertension
stroke
Pan et al Cephalalgia 2011; 31(8):937-942
Pan et al Neurology 2011; 77(17):1605-1610.
HCP making diagnosis TN = 5287 ATN = 189 OFP = 857
General medical
practitioner (%) 36 36 18
Neurologist (%) 29 30 17
Dentist (%) 20 15 10
Other specialists (%) 15 19 55
Stories have :
• A teller
• A listener
• A language
• Characters
• A plot
• Time
Marshall & Bleakley Med Hum 2013 : 0: 1-6
Which metaphors used in TN?
1. Rock in my ear and a string pulling it
2. Firework exploding
3. Drums beating
4. Electric needles
5. Plugged into the mains, switched on/off
6. Clamp
7. Heavy brick inside the head
8. Ants crawling
9. Lightening
10.Weight inside the face getting heavier
1 2 3 4
Flickering Jumping Pricking Sharp
Quivering Flashing Boring Cutting
Pulsing Shooting Drilling Lacerating
Throbbing Stabbing
Beating Lancinating
Pounding
5 6 7 8
Pinching Tugging Hot Tingling
Pressing Pulling Burning Itchy
Gnawing Wrenching Scalding Smarting
Cramping Searing Stinging
Crushing
9 10 11 12
Dull Tender Tiring Sickening
Sore Taut Exhausting Suffocating
Hurting Rasping
Aching Splitting
Heavy
13 14 15 16
Fearful Punishing Wretched Annoying
Frightful Gruelling Blinding Troublesome
Terrifying Cruel Miserable
Vicious Intense
Killing Unbearable
17 18 19 20
Spreading Tight Cool Nagging
Radiating Numb Cold Nauseating
Penetrating Drawing Freezing Agonizing
Piercing Squeezing Dreadful
Tearing Torturing
MPQ
Which
words
chosen by
TN?
Table 2. Statistically significant words for discriminating between TN and CIFP (p<0.05).
Use of McGill Pain Questionnaires (MPQ) in discriminating
between trigeminal neuralgia and chronic idiopathic facial pain
Joanna M Zakrzewska§, Mee-Eun Kim§, Teekyu Plangkoon Jorns*
UCL Eastman Dental Institute, 256 Gray’s Inn Road, London WC1X 8LD§
Khon Kaen University, Khon Kaen, Thailand* Email [email protected]
TN n=162 CIFP n= 93
Sensory
flashing, shooting,
stabbing, sharp,
wrenching, hot, searing,
splitting
throbbing, boring,
pressing,
pulling, dull,
aching, tender
Affective exhausting, fearful,
terrifying, vicious tiring
Evaluative intense annoying
Miscellaneous tearing, agonizing,
torturing
radiating,
piercing, tight, squeezing,
nagging, nauseating
Psychological areas of the brain activated
in non evoked trigeminal pain
Tolle et al Pain Practice 2006
Depression and Anxiety
During the last month have you often been
bothered by:
1. Feeling down, or depressed or hopeless?
2. Having little interest or pleasure in doing things ?
Pilling BMJ 2009
NICE guidelines © Green BMJ
© Zakrzewska
Medical management
© Zakrzewska
Which have been evaluated in
Randomised controlled trials - RCTs?
baclofen carbamazepine
valproate lamotrigine epanutin
clonazepam
© Zakrzewska
Which have been evaluated in RCTs?
gabapentin
pregabalin oxcarbazepine
sumatriptan
leviteracetam
Dextromethorphan
Topiramate
Botox
New drug for TN
Systematic reviews surgery
3 studies
2 radiofrequency
thermocoagulation
comparing techniques
1 stereotactic surgery
comparing dosages
Cochrane Database of Systematic Reviews 2011, Issue 9.
Grading
Improving quality
Editorial
AAN/EFNS guidelines
Outcomes
Therapy % pain
relief
Decreased
intensity
frequency
Character of pain
Provoking factors
Side
effects
Beliefs
concerns
Objective
measures
© Zakrzewska
Psychological interventions for
chronic pain: CBT approach
Thoughts/ Cognitions
Physiology Behaviours
Feelings/ Emotions
Miller, 1991; Turk et al., 1983
Support groups US , UK, Australia , Canada
Web sites : http://www.tna-support.org/
http://www.tna.org.uk/
© Zakrzewska
Microvascular
decompression
MS
Drug
therapy
Neurovascular compression
Drug therapy
Tumours etc
Idiopathic TN
MRI
Blood tests Symptomatic TN
Ablative procedures Gasserian
ganglion
Gamma knife
Trigeminal neuralgia Primary care
Carbamazepine
Initial good control but now failing
Refer pain clinic
Neurology headache
Neurosurgery Poor
quality of
life
Carbamazepine
Oxcarbazepine
Lamotrigine
Baclofen
Pregablin
Gabapetin
Joint neurosurgery
clinic Psychology
© Zakrzewska
References – HCP Patients
TN Review BMJ 2014
Choice, Option, Decision
http://www.advancingqualityalliance.nhs.uk/SDM
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