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Trigeminal neuralgia — Clinical Guidelines

Overview

Trigeminal neuralgia (TN) is characterized by severe, episodic facial pain along the distribution of one or more branches of the trigeminal nerve, often triggered by innocuous stimuli 1 2.

Diagnosis

Clinical Presentation: Characteristic paroxysmal, sharp, lancinating pain 1 2.

Neurological Examination: Typically normal unless secondary causes are present 1 2.

Imaging: MRI to rule out structural causes such as vascular compression, tumors, or demyelination 3 4 15.

Electrophysiological Tests: Not routinely required but may help in complex cases 6.

Management

First-Line Treatments:

- Anticonvulsants: Carbamazepine, oxcarbazepine (monitor for adverse effects) 5. - Tricyclic Antidepressants: Amitriptyline 5.

Adjunctive Treatments:

- Monoclonal Antibodies: Erenumab (CGRP receptor antagonist) for refractory cases 1. - Radiosurgery: Gamma Knife radiosurgery for long-term pain control 17. - Surgical Interventions: Microvascular decompression (MVD) for refractory cases, particularly effective in elderly patients 10 18. - Percutaneous Procedures: Glycerol rhizolysis for pain relief 21. - Emergency Management: Fosphenytoin for acute pain crises 16.

Special Populations

Elderly: Microvascular decompression remains effective with acceptable risks 10.

Comorbidities: Microvascular decompression can be beneficial in patients with multiple sclerosis 18.

Key Recommendations

Initiate with Anticonvulsants: Carbamazepine or oxcarbazepine as first-line pharmacological treatments for trigeminal neuralgia (Evidence: Strong 5).

Consider Radiosurgery for Refractory Cases: Gamma Knife radiosurgery offers effective long-term pain relief for patients with idiopathic trigeminal neuralgia (Evidence: Moderate 17).

Evaluate Structural Causes with MRI: Utilize MRI to identify potential causes like vascular compression or tumors before considering surgical interventions (Evidence: Moderate 3 4 15).

Use Erenumab for Refractory Cases: Erenumab can be considered for patients with refractory trigeminal neuralgia due to its efficacy in modulating pain pathways (Evidence: Weak 1).

Microvascular Decompression in Elderly Patients: MVD remains a viable option with good outcomes in elderly patients with medically refractory trigeminal neuralgia (Evidence: Moderate 10).

References

1 Schott Andersen AS, Maarbjerg S, Noory N, Heinskou TB, Forman JL, Cruccu G et al.. Safety and efficacy of erenumab in patients with trigeminal neuralgia in Denmark: a double-blind, randomised, placebo-controlled, proof-of-concept study. The Lancet. Neurology 2022. link00294-0) 2 Aghamohammadi D, Sharifi S, Shakouri SK, Eslampour Y, Dolatkhah N. Autologous conditioned serum (Orthokine) injection for treatment of classical trigeminal neuralgia: results of a single-center case series. Journal of medical case reports 2022. link 3 Henssen D, Dijk J, Knepflé R, Sieffers M, Winter A, Vissers K. Alterations in grey matter density and functional connectivity in trigeminal neuropathic pain and trigeminal neuralgia: A systematic review and meta-analysis. NeuroImage. Clinical 2019. link 4 Easwer HV, Chatterjee N, Thomas A, Santhosh K, Raman KT, Sridhar R. Usefulness of flat detector CT (FD-CT) with biplane fluoroscopy for complication avoidance during radiofrequency thermal rhizotomy for trigeminal neuralgia. Journal of neurointerventional surgery 2016. link 5 Besi E, Boniface DR, Cregg R, Zakrzewska JM. Comparison of tolerability and adverse symptoms in oxcarbazepine and carbamazepine in the treatment of trigeminal neuralgia and neuralgiform headaches using the Liverpool Adverse Events Profile (AEP). The journal of headache and pain 2015. link 6 Naka A, Wolf A, Renner B, Mueller CA. A novel device for the clinical assessment of intranasal trigeminal sensitivity. The Annals of otology, rhinology, and laryngology 2014. link 7 Chen Y, Kanju P, Fang Q, Lee SH, Parekh PK, Lee W et al.. TRPV4 is necessary for trigeminal irritant pain and functions as a cellular formalin receptor. Pain 2014. link 8 Pearce JM. John Fothergill: a biographical sketch and his contributions to neurology. Journal of the history of the neurosciences 2013. link 9 Pauls RJ, Dickson TJ, Kaufmann AM, Cappellani RB, Ringaert KR, West M et al.. A comparison of the ability of the EEGo and BIS monitors to assess emergence following neurosurgery. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2009. link 10 Günther T, Gerganov VM, Stieglitz L, Ludemann W, Samii A, Samii M. Microvascular decompression for trigeminal neuralgia in the elderly: long-term treatment outcome and comparison with younger patients. Neurosurgery 2009. link 11 Simon SD, Yao TL, Rosenbaum BP, Reig A, Mericle RA. Resolution of trigeminal neuralgia after palliative embolization of a cerebellopontine angle arteriovenous malformation. Central European neurosurgery 2009. link 12 Cheshire WP. Trigeminal neuralgia in wind musicians. Headache 2006. link 13 Peker S, Akansel G, Sun I, Pamir NM. Trigeminal neuralgia due to pontine infarction. Headache 2004. link 14 Umino M, Kohase H, Ideguchi S, Sakurai N. Long-term pain control in trigeminal neuralgia with local anesthetics using an indwelling catheter in the mandibular nerve. The Clinical journal of pain 2002. link 15 Brisman R, Khandji AG, Mooij RB. Trigeminal Nerve-Blood Vessel Relationship as Revealed by High-resolution Magnetic Resonance Imaging and Its Effect on Pain Relief after Gamma Knife Radiosurgery for Trigeminal Neuralgia. Neurosurgery 2002. link 16 Cheshire WP. Fosphenytoin: an intravenous option for the management of acute trigeminal neuralgia crisis. Journal of pain and symptom management 2001. link00269-x) 17 Maesawa S, Salame C, Flickinger JC, Pirris S, Kondziolka D, Lunsford LD. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. Journal of neurosurgery 2001. link 18 Broggi G, Ferroli P, Franzini A, Pluderi M, La Mantia L, Milanese C. Role of microvascular decompression in trigeminal neuralgia and multiple sclerosis. Lancet (London, England) 1999. link94422-7) 19 Eide PK, Stubhaug A. Relief of trigeminal neuralgia after percutaneous retrogasserian glycerol rhizolysis is dependent on normalization of abnormal temporal summation of pain, without general impairment of sensory perception. Neurosurgery 1998. link 20 Bouhassira D, Attal N, Estève M, Chauvin M. "SUNCT" syndrome. A case of transformation from trigeminal neuralgia?. Cephalalgia : an international journal of headache 1994. link 21 Young RF. Glycerol rhizolysis for treatment of trigeminal neuralgia. Journal of neurosurgery 1988. link 22 Burchiel KJ, Clarke H, Haglund M, Loeser JD. Long-term efficacy of microvascular decompression in trigeminal neuralgia. Journal of neurosurgery 1988. link 23 Harper N. Trigeminal trophic syndrome. Postgraduate medical journal 1985. link 24 Rappaport ZH. Epidermoid tumour of the cerebellopontine angle as a cause of trigeminal neuralgia. Neurochirurgia 1985. link 25 Sato O, Kanazawa I, Kokunai T. Trigeminal neuralgia caused by compression of trigeminal nerve by pontine vein. Surgical neurology 1979. link 26 Wüllenweber R, Traupe H, Schwarz G. Angiographic demonstration of a trigeminal neurinoma. Neuroradiology 1976. link

Trigeminal neuralgia