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 jzakrzewska@nhs.net

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