TRIGEMINAL NEURALGIA (tic douloureux)
Trigeminal neuralgia is characterised by paroxysmal attacks of severe, short, sharp, stabbing pain affecting one or more divisions of the trigeminal nerve. The pain involves the second or third divisions more often than the first; it rarely occurs bilaterally, and never simultaneously on each side, occasionally more than one division is involved. Paroxysmal attacks last for several days or weeks; they are often superimposed on a more constant ache. When the attacks settle, the patient may remain pain free for many months.
Chewing, speaking, washing the face, tooth-brushing, cold winds, or touching a specific 'trigger spot', e.g. upper lip or gum, may all precipitate an attack of pain.
Trigeminal neuralgia more commonly affects females and patients over 50 years of age.
In many patients the cause remains unexplained, as do the long periods of remission. Trigeminal pain may be symptomatic of disorders which affect the nerve root or its entry zone.
Root or root entry zone compression - tumours of the cerebellopontine angle lying against the V nerve roots, e.g. meningioma, epidermoid cyst, frequently present with trigeminal pain.
- arterial vessels often abut and sometimes clearly indent the trigeminal nerve root at the entry-zone into the pons.
Demyelitiation - such a lesion in the pons should be considered in a 'young' person with trigeminal neuralgia. Trigger spots are rare. Remission occurs infrequently and the response to drug treatment is poor.
CT or preferably MR scan to exclude a cerebello-pontine angle lesion.
CARBAMAZHPINE proves effective in most patients (and helps confirm the diagnosis). Provided toxicity does not become troublesome, i.e. drowsiness, ataxia, the dosage is increased until pain relief occurs (600-1600 mg/day). When remission is established, drug treatment can be discontinued.
If pain control is limited, other drugs - BACLOFEN, LAMOTRIGINE, PIMOZIDE (dopamine receptor antagonist), PHENYTOIN - may benefit.
Persistence of pain on full drug dosage or an intolerance of the drugs, indicates the need for more radical measures.
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