Trigeminal neuralgia
Questionnaire/history:
Paroxysmal attacks of facial pain lasting from seconds to minutes?Affecting V2 maxillary (nearly always) and/or V3 mandibular divisions of TN?
Pain history:
- Intense?
- Sharp?
- Superficial?
- Stabbing (often like an electric shock)?
Pain frequency (eg infrequent or hundreds of times a day)?
Triggers?
- Light touch?
- Eating?
- Talking?
- Washing face?
- Wind?
- Cleaning teeth?- Other?
Autonomic features (eg conjunctival injection, lacrimation, rhinorrhoea) (rarely)?
Atypical or 'mixed' trigeminal neuralgia (type 2) with persistent discomfort between paroxysms?
Known cause? Compression of the trigeminal nerve root at the root entry zone by an aberrant vascular loop (usually superior cerebellar artery)?
Vascular malformations?
Posterior fossa tumours?
MS?
Invasive skin tumours?
Dental problems?
Red flags requiring referral?
Sensory change on examination, deafness or other ear problems?
History of skin or oral lesions that could spread
Pain in ophthalmic division (eye socket, forehead, nose)
Optic neuritis or family history of MS
Age <40
Management:
Carbamazepine (licensed for trigeminal neuralgia) first line:
Start at 100 mg twice daily and slowly titrate the dosage (eg 100-200mg every 2 weeks) until pain is relieved (maximum dosage 1600 mg daily)
Once the pain is in remission, the dosage should be gradually reduced to the lowest possible maintenance level, maximum recommended dose: 1200 mg daily
(Note: Modified release preparations may be useful at night if the person experiences breakthrough pain, 75% of patients will respond)
Early follow-up
Refer to a neurologist if severe pain or pain significantly affecting daily activitie
Alternative treatments on specialist advice:
Oxcarbazepine (lower toxicity than carbamazepine, results as good)
Lamotrigine (limited evidence)
Gabapentin (little evidence)
Baclofen (consensus that may be effective if a patient has)
Resource(s):