Oral Biosciences & Medicine
Oral Biosci Med 1 (2004), No. 1     10. Mar. 2004

Oral Biosci Med 1/2004, S. 61-73

Trigeminal Neuralgia Diagnosis and Management - a Teaching Module

Joanna M. Zakrzewska a

Abstract

Summary:
Below you will find a series of slides that were originally designed for an interactive Internet learning scheme, which provides an evidence based overview of the diagnosis and management of trigeminal neuralgia, a rare cause of facial pain. Although rare it is very important that any healthcare professional dealing with the face and mouth is able to recognize the condition as the management of this condition is very different from of the treatment of other orofacial pains. To make the most of this teaching aid the slides were designed to be viewed with the additional notes provided. The answers to the two exercises are provided at the end of the presentation. In addition you may wish to try the four questions listed below as part of your continuing professional development. The answers can be found at the end of this article.


QUESTIONS

  1. List the key features of trigeminal neuralgia.
  2. How could you try to 'measure' pain in a way that you could apply to future evaluation of your treatment?
  3. Mrs B is a fit 60-year-old woman with a 4-year history of classical trigeminal neuralgia. She has been pain free and off all medication for 6 months but in the last two weeks the pain has returned and is having a significant impact on her life.
    a. What will you do in the short term?
    b. What will you do in the long term?
    c. How can you improve compliance with treatment?
  4. Which drugs have been evaluated by randomised controlled trials and shown to be effective in the treatment of trigeminal neuralgia?

Slide 1



Slide 2



Slide 3



Slide 41)



Slide 5



Slide 62)



Slide 73)



Slide 84)


Table 1 McGill pain questionnaire

MCGILL PAIN QUESTIONNAIRE

NAME:

DATE:

Circle the word that describes how your pain feels right now:

Nil

Mild

Moderate

Severe

Most Severe

Circle the words below that best described your current pain:

Use only one word in each group.

Leave out any group if the words are unsuitable.


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

Stinging

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


Table 2 Case studies for trigeminal neuralgia slide show

Please read these three case histories: do these patients have trigeminal neuralgia? How may you proceed to manage those with trigeminal neuralgia?

Case

1

2

3


Age


71


54


57

Gender

Female

Female

Female

Development of pain

Slowly developed first 5 years ago, there have been periods of weeks when there has been no pain

Constant over about 5 years, recent exacerbation which has not settled as usual, has not taken any medication for it as it was not "that bad".

First episode of pain 1.5 years ago beginning suddenly. Lasted for several weeks and then no pain for 9 months. Present episode of pain began 2 months ago after eating a meal.

Character/quality
Words from McGill pain questionnaire

Quivering, jumping, pricking, sharp, gnawing, burning, stinging, aching, tender, tiring, wretched, annoying, piercing, numb, nagging

Aching heavy, nagging sometimes throbbing and sharp

Quivering, shooting, stabbing, sharp, crushing, tingling, aching, tender, tiring, terrifying, killing, blinding, unbearable, piercing, tight, agonizing

Site and radiation

Right mandible and nasolabial area, always the same area, felt deep in the face

Whole of the right side of the face

Left mental area is the trigger point and pain radiates up along the whole of the third division of the trigeminal nerve occasionally radiating to the outer canthus of the eye.

Severity Visual analogue scale 0-10 cm

At its worse 6 cm, mean of 3 cm, pain may go completely

Average 3.7 cm, at its worse 6 cm

Worse 9 cm, average of 4 cm, times when there is no pain.

Duration and periodicity

Each burst of pain lasts a few seconds these may repeat in episodes every few hours, periods of weeks of complete pain relief. Often left with a dull mild gnawing background pain.

Constant with intermittent severe episodes

Each pain episode lasts a few seconds but there may be bouts of these pains many times a day, may be no pain for a week or two. No pain at night

Provoking factors

Eating and brushing the teeth starts up pain

Opening mouth, eating, chewing and touching the area

Eating, talking, attempting to put make up on her lower lip, washing lower part of the face

Relieving factors

No activities

Nil

No activities

Associated factors

Some neck pain but no other pain or disturbances

Sometimes the area feels warm and appears reddened

Smoking makes the pain worse

Effect of pain on life style

Unable to socialise as much as would like, no evidence of anxiety or depression.

Divorced. Does not work, has had some impact on social life

Has a considerable effect on her quality of life, took a week of work as could not do her job as a personal secretary

Examination

No gross abnormalities, full denture wearer

No cranial nerve abnormalities and fully dentate with no dental disease

No cranial nerve abnormalities and fully dentate with no dental disease



Slide 95)



Slide 106)



Slide 11



Slide 127)



Slide 13



Slide 14



Slide 158)



Slide 169)



Slide 1710)



Slide 1811)



Slide 1912)



Slide 2013)



Slide 2114)



Slide 2215)



Slide 2316)



Slide 2417)



Slide 2518)



Slide 2619)



Slide 2720)



Slide 2821)



Slide 2922)



Slide 3023)



Slide 3124)



Slide 3225)



Slide 3326)


ANSWERS

  1. See slides 6-7
  2. See slides 8-9
  3. a. If she has responded well to carbamazepine in the past start on this and work up to a dose around 800mg daily, give the patient a pain diary
    b. Consider referral to a neurosurgeon for possible microvascular decompression as patient has classical trigeminal neuralgia and is medically fit. If the patient does not wish to have surgery but suffers side effects from medication may wish to change to other anticonvulsant therapy.
    c. Provide more patient information, provide contact with support group involve patient in decision making.
  4. Carbamazepine, baclofen, lamotrigine

REFERENCES

  1. Brain and Spine Foundation Face Pain booklet ISBN 1 901893 16 2:2002; or http://www.brainandspine.org.uk
  2. Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic Review of Ablative Neurosurgical Techniques in the Management of Trigeminal Neuralgia Neurosurgery. In press.
  3. Melzack R, Terrence C, Fromm G, Amsel R. Trigeminal neuralgia and atypical facial pain: use of the McGill Pain Questionnaire for discrimination and diagnosis. Pain 1986;27:297-302.
  4. Merskey H, Bogduk N. Classification of chronic pain. Descriptors of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press 1994;59-60.
  5. Newton-John T. Measurement of pain in adults in Assessment and management of orofacial pain. In: Zakrzewska JM, Harrison S (eds). Pain research and clinical management, volume 14. Amsterdam: Elsevier Sciences 2002;87-104.
  6. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia - pathophysiology, diagnosis and current treatment. Br J Anaesth 2001;87:117-132.
  7. Olesen J. The international classification of headache disorders. 2nd edition. Cephalalgia 2004;24:1:126-127.
  8. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999;83:389-400.
  9. Weigel G, Casey KF. Striking Back. The trigeminal neuralgia handbook. Barnegat Light: The Trigeminal Neuralgia Association 2000.
  10. Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Syst Rev 2000;CD001133.
  11. Zakrzewska JM. Trigeminal neuralgia. London: Saunders 1995;78.
  12. Zakrzewska J.M, Patsalos PN. Long term cohort study comparing medical (oxcarbazepine) and surgical management of intractable trigeminal neuralgia Pain 2002;95:259-266.
  13. Zakrzewska JM, Lopez BC. Quality of papers reporting outcomes after surgical management of trigeminal neuralgia. Recommendations for future reports. Neurosurgery 2003;53:110-122.
  14. Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)
  15. Zakrzewska JM. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain 2002;18:14-21.
  16. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

Notes:

1) Merskey H, Bogduk N. Classification of chronic pain. Descriptors of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press 1994;59-60.

2) These diagnostic criteria have not been validated by case control studies. Olesen J. The international classification of headache disorders. 2nd edition. Cephalalgia 2004;24:126-127. Zakrzewska JM. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain 2002;18:14-21. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia - pathophysiology, diagnosis and current treatment. Br J Anaesth 2001;87:117-132.

3) Not all patients fit these criteria and some patients will also complain of aching, dull background pain that tends to be more continuous. This type of 'after pain' is often found in other neuropathic pain syndromes. When treated surgically these patients often have some remaining dull pain as surgery seems to be mainly effective against sharp pain. This type of pain has been labelled as atypical trigeminal neuralgia. If this has been ascertained prior to surgery patients can be told that surgery may not give complete pain relief.

4) The McGill Questionnaire text can be found in Table 1. Newton-John T. Measurement of pain in adults in Assessment and management of orofacial pain. In: Zakrzewska JM, Harrison S (eds). Pain research and clinical management, volume 14. Amsterdam: Elsevier Sciences 2002;87-104.

5) This study looked at 95 patients who fulfilled the criteria for trigeminal neuralgia with 100 who had atypical facial pain (AFP) or chronic idiopathic facial pain. Zakrzewska JM. Trigeminal neuralgia. London: Saunders 1995; 78. This was based on a study done by Melzack and Fromm. Melzack R, Terrence C, Fromm G, Amsel R. Trigeminal neuralgia and atypical facial pain: use of the McGill Pain Questionnaire for discrimination and diagnosis. Pain 1986;27:297-302.

6) This poem was written by a patient with trigeminal neuralgia.

7) Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2002; CD001133. (The Cochrane review is updated usually every two years) Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)

8) Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999;83:89-400. Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)

9) Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2002; CD001133. (The Cochrane review is updated usually every two years) Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)

10) The references provided have all the individual references to the original studies included in the reviews. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999;83:89-400. There is a regular annual update in the journal Clinical Evidence with the latest updates being available on its internet site. Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)

11) No RCTs, case reports only. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

12) No RCTs. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

13) No RCTs. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

14) No randomised controlled trial but there is a longitudinal cohort study. Zakrzewska JM, Patsalos PN. Long term cohort study comparing medical (oxcarbazepine) and surgical management of intractable trigeminal neuralgia. Pain 2002;95:259-266.

15) These diaries are a good way of getting patients involved and in control of their pain. Patients can decide on their own format. For trials electronic diaries would be better.

16) Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999;83:389-400. Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Syst Rev 2000;CD001133. Zakrzewska JM, Lopez BC. Trigeminal neuralgia. Clinical evidence concise 2003;9:280-281. (Latest version www.clinicalevidence.com)

17) There are few high quality trials of surgical management. As the trials are not randomised there is no way of knowing whether the surgery worked because of a natural period of pain remission. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia - pathophysiology, diagnosis and current treatment. Br J Anaesth 2001;87:117-132. Zakrzewska JM, Lopez BC. Quality of papers reporting outcomes after surgical management of trigeminal neuralgia. Recommendations for future reports. Neurosurgery 2003;53:110-122. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370. Zakrzewska JM. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain 2002;18:14-21.

18) These techniques depend on localising a trigger spot and all can be done on an outpatient basis. Most are neuro-destructive and will cause local sensory loss. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

19) Descriptions of these techniques can be found in a variety of textbooks and articles. These involve inserting a needle into the Gasserian ganglion and producing nerve damage. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia - pathophysiology, diagnosis and current treatment. Br J Anaesth 2001;87:117-132. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

20) Descriptions of these techniques can be found in a variety of textbooks and articles. MVD is a non ablative procedure which involves decompressing the trigeminal nerve usually caused by an artery. Partial rhizotomy is done when no compression is found and a part of the nerve is cut. Gamma knife surgery is an ablative procedure which delivers radiation to the trigeminal nerve in the posterior fossa. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia - pathophysiology, diagnosis and current treatment. Br J Anaesth 2001;87:117-132. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

21) Using only the top quality studies these Kaplan Meir survival curves show tat microvascular decompression gives the longest period of pain relief - 70% at ten years will be pain free whereas ablative techniques provide 4-5 years of pain free time. Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic Review of Ablative Neurosurgical Techniques in the Management of Trigeminal Neuralgia Neurosurgery. In press. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

22) These complications show that peri-operative complications are highest after MVD and the commonest complication is loss of hearing around 4%. All other procedure result in complications related to trigeminal dysfunction - sensory loss in a variety of degrees. Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic Review of Ablative Neurosurgical Techniques in the Management of Trigeminal Neuralgia Neurosurgery. In press. Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

23) Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;267-370.

24) Patients greatly appreciate receiving more information as there is very little around. Both these support groups offer a range of materials and other countries have now set up groups e.g. Australia, and Spine Foundation Face Pain booklet ISBN 1 901893 16 2: 2002; or http://www.brainandspine.org.uk Weigel G, Casey KF. Striking Back. The trigeminal neuralgia handbook. Barnegat Light: The Trigeminal Neuralgia Association 2000.

25) Case 1 - This patient also describes a dull type of pain which is more persistent and more in line with a neuropathic pain. It has been suggested that these patients show evidence of long term compression and nerve atrophy. Case 2 - Although unilateral and with some sharp elements has an over riding constant pain. Case 3 - This is a classical trigeminal neuralgia with all the diagnostic features as shown in slide 4.

26) An algorithm for management can be found in Zakrzewska JM. Trigeminal neuralgia. In: Zakrzewska JM, Harrison SD (eds). Assessment and management of orofacial pain. Amsterdam: Elsevier Sciences 2002;354.

Authors:

a Joanna M. Zakrzewska
Barts and the London Queen Mary's School of Medicine and Dentistry, London, UK.

Joanna M. Zakrzewska, Senior Lecturer/Hon Consultant in Oral Medicine, Barts and the London Queen Mary's School of Medicine and Dentistry, Turner Street, London E1 2AD, UK, E-mail J.M.Zakrzewska@qmul.ac.uk