Introduction to Introduction to Trigeminal Neuralgia Trigeminal - - PowerPoint PPT Presentation

Introduction to Introduction to Trigeminal Neuralgia Trigeminal Neuralgia

ฑีฆายุ ฑีฆายุ พลางกูร พลางกูร จอรนส จอรนส

Teekayu Teekayu Plangkoon Plangkoon J JÖ ÖRNS RNS

Objectives Objectives

Historical background of the condition Historical background of the condition Epidemiology Epidemiology Clinical features Clinical features Pathophysiology Pathophysiology of TN

• f TN

Diagnostic criteria and differential Diagnostic criteria and differential diagnosis diagnosis Clinical assessment of TN Clinical assessment of TN

Historical Background Historical Background

11 11th

th century Arab physician

century Arab physician Jurjani Jurjani (1066 (1066 – – 1136) 1136)’ ’s book s book

“ “ There is a type of pain which effects the teeth on one There is a type of pain which effects the teeth on one side and the whole of the jaw on the side which is side and the whole of the jaw on the side which is

• painful. With the pain there is spasm of the face and
• painful. With the pain there is spasm of the face and

severe anxiety severe anxiety… ….. .. The cause of spasm and anxiety is The cause of spasm and anxiety is the proximity of the artery to the nerve the proximity of the artery to the nerve. .” ”

Nicolaus Nicolaus Andr André é (1756) described 5 cases (1756) described 5 cases tic tic douloureux douloureux (unbearably painful twitch) (unbearably painful twitch)

Historical Background Historical Background

John Fothergill (1773) John Fothergill (1773) – – published a full published a full account of account of tic tic douloureux douloureux and presented a and presented a paper to the medical society of London paper to the medical society of London Fothergill Fothergill’ ’s disease s disease (Dolor (Dolor Faciei Faciei Fothergillii Fothergillii) ) Pujol Pujol (1787) discussed the diagnostic (1787) discussed the diagnostic confusion of confusion of tic tic douloureux douloureux and and pain of pain of dental origin dental origin

Historical Background Historical Background

Charles Bell (1829) confirmed that Charles Bell (1829) confirmed that trigeminal nerve (the V nerve) trigeminal nerve (the V nerve) was was identified as a distinct nerve from facial identified as a distinct nerve from facial nerve. nerve. Trigeminal Neuralgia (TN) Trigeminal Neuralgia (TN)

Epidemiology of TN Epidemiology of TN

TN is a rare condition TN is a rare condition (incidence = 4.5 / 100,000) (incidence = 4.5 / 100,000) The peak incidence is in 60 The peak incidence is in 60-

• 70 age group

70 age group Women are more likely to get TN Women are more likely to get TN At increased risk of developing TN are patients At increased risk of developing TN are patients with with multiple sclerosis multiple sclerosis (MS is seen in 2 (MS is seen in 2-

• 4 % of

4 % of TN patients) and TN patients) and hypertension hypertension

Zakrzewska Zakrzewska JM, JM, Hamlyn Hamlyn PJ. Facial pain. Epidemiology of Pain. IASP, Seattle, WA,

• PJ. Facial pain. Epidemiology of Pain. IASP, Seattle, WA,

1999: 171 1999: 171-

• 202

202

Clinical features Clinical features

Character of pain Character of pain Radiation Radiation Site Site Severity Severity Onset of pain Onset of pain Provoking factors Provoking factors Relieving factors Relieving factors

Character of pain Character of pain

Sharp , shooting , Sharp , shooting , stabbing, unbearable, like stabbing, unbearable, like lightning or an electric lightning or an electric shock, cattle prod shock, cattle prod McGill Pain McGill Pain Questionnaires (MPQ), Questionnaires (MPQ), 78 adjective words 78 adjective words describing pain describing pain ( (Melzack Melzack, 1975) , 1975)

Melzack R, Terrence C, Fromm G, Amsel R . Trigeminal neuralgia and atypical facial pain: use

• f the McGill Pain Questionnaire for discrimination and diagnosis. Pain 1986; 27(3):297-302

Site and Radiation Site and Radiation

Distribution of trigeminal Distribution of trigeminal nerve nerve Nearly always unilateral Nearly always unilateral Total right 61% , Total left Total right 61% , Total left 36%, Total bilateral 3% 36%, Total bilateral 3% V1 = 4% V1 = 4% V2 = 17% V2 = 17% V3 = 15% V3 = 15% V1+V2 = 14% V1+V2 = 14% V2+V3 = 32% V2+V3 = 32% V1+V2+V3 = 17% V1+V2+V3 = 17%

Likely sites of trigger TN pain Likely sites of trigger TN pain

Severity Severity

TN pain can be TN pain can be suicidal suicidal The MPQ shows The MPQ shows both sensory and both sensory and affective elements are affective elements are high high VAS (Visual Analogue VAS (Visual Analogue Scale) Scale)

Timing , duration and onset Timing , duration and onset

Paroxysmal attack and a pain Paroxysmal attack and a pain-

• free (refractory)

free (refractory) intervals between attacks, memorable first attack intervals between attacks, memorable first attack Pain of abrupt onset and equally abrupt termination Pain of abrupt onset and equally abrupt termination Remission period Remission period

Differences between TN and Differences between TN and neuropathic neuropathic pain pain

Paroxysmal with long pain free intervals Paroxysmal with long pain free intervals No abnormal sensations No abnormal sensations No build up of pain, refractory periods No build up of pain, refractory periods Responds to surgical treatment Responds to surgical treatment

Provoking and relieving factors Provoking and relieving factors

Provoking Provoking

• Light touched

Light touched provoked i.e. provoked i.e. washing, shaving, washing, shaving, smoking, talking, smoking, talking, drinking, brushing drinking, brushing teeth, making up teeth, making up

• Mechanical

Mechanical

• Thermal

Thermal Relieving Relieving

• Rest and relaxation

Rest and relaxation

• Local

Local anaesthetic anaesthetic agent agent

• Anticonvulsants

Anticonvulsants ( (carbamazepine carbamazepine) )

• Surgery

Surgery

• Spontaneous

Spontaneous remisssion remisssion

Why is the right diagnosis Why is the right diagnosis important? important?

Proper managements and referrals Proper managements and referrals Recruit patients into trials Recruit patients into trials

“ “Words matter, because what you describe will make a Words matter, because what you describe will make a different in treatment different in treatment” ”

• Dr Kim

Dr Kim Burchiel Burchiel, chief of neurosurgery, Oregon Health Sciences University, , chief of neurosurgery, Oregon Health Sciences University, Oregon, USA Oregon, USA

“ “Before we start giving a lot of medicines, we ought to be Before we start giving a lot of medicines, we ought to be sure of the diagnosis sure of the diagnosis” ”

• Dr Joanna

Dr Joanna Zakrzewska Zakrzewska, Oral Medicine, , Oral Medicine, Barts Barts and The London School of and The London School of Medicine and Dentistry, London, UK Medicine and Dentistry, London, UK

Trigeminal Neuralgia Trigeminal Neuralgia IASP Classification (1994) IASP Classification (1994)

Sudden, severe, brief, recurrent stabbing Sudden, severe, brief, recurrent stabbing pain in the distribution of the trigeminal pain in the distribution of the trigeminal nerve nerve (IASP, 1994) (IASP, 1994) 1.

• 1. Trigeminal neuralgia (Tic

Trigeminal neuralgia (Tic Douloureux Douloureux) ) 2.

• 2. Secondary trigeminal neuralgia from

Secondary trigeminal neuralgia from CNS lesions CNS lesions 3.

• 3. Secondary trigeminal neuralgia from

Secondary trigeminal neuralgia from facial trauma facial trauma

Diagnostic Criteria of Trigeminal Diagnostic Criteria of Trigeminal Neuralgia by the IHS (2004) Neuralgia by the IHS (2004)

• 1. Classical trigeminal
• 1. Classical trigeminal

neuralgia neuralgia

• 2. Symptomatic
• 2. Symptomatic

trigeminal neuralgia trigeminal neuralgia

Cephalalgia,2003 vol. 24 Cephalalgia,2003 vol. 24 suppl suppl 1, 1,

• pp. 126
• pp. 126-
• 127

127

Diagnostic Criteria of TN (2004) Diagnostic Criteria of TN (2004)

Classical trigeminal neuralgia Classical trigeminal neuralgia

The International Headache Society (IHS) The International Headache Society (IHS) Paroxysmal attacks of pain (fraction of a second Paroxysmal attacks of pain (fraction of a second to 2 minutes) to 2 minutes) Pain has Pain has at least one at least one of the following

• f the following

characteristics characteristics

– – Intense, sharp, superficial or stabbing Intense, sharp, superficial or stabbing – – Precipitated from trigger areas or by trigger factors Precipitated from trigger areas or by trigger factors

Attacks are stereotyped Attacks are stereotyped No clinically evident neurological deficit No clinically evident neurological deficit Not attributed to another disorder Not attributed to another disorder

Atypical Trigeminal Neuralgia Atypical Trigeminal Neuralgia (TN Type II) (TN Type II)

Sharp but also burning aching background Sharp but also burning aching background pain pain Pain can persist over 2 minutes Pain can persist over 2 minutes They tend to benefit less from They tend to benefit less from interventional treatments interventional treatments

refractory pain free period

The Liverpool classification The Liverpool classification for TN for TN

British Journal of British Journal of Anaesthesia Anaesthesia 87 (1) : 117 87 (1) : 117-

• 32 (2001)

32 (2001)

The Liverpool The Liverpool criteria 2001 criteria 2001 (T.J.

(T.J. Nurmikko Nurmikko and P.R. Eldridge, and P.R. Eldridge, The Walton centre for The Walton centre for neurology and neurosurgery, neurology and neurosurgery, Liverpool, UK) Liverpool, UK)

1.

• 1. Typical TN

Typical TN

• 2. Atypical TN
• 2. Atypical TN
• 3. Trigeminal
• 3. Trigeminal

neuropathy neuropathy

A new classification for A new classification for facial pain facial pain

Burchiel Burchiel KJ. Neurosurgery 2003 Nov;53 (5): 1164

• KJ. Neurosurgery 2003 Nov;53 (5): 1164-
• 7

7

Burchiel Burchiel classification classification 1.Trigeminal neuralgia type I 1.Trigeminal neuralgia type I 2.Trigeminal neuralgia type II 2.Trigeminal neuralgia type II 3.Trigeminal 3.Trigeminal neuropathic neuropathic pain pain 4.Trigeminal 4.Trigeminal deafferentation deafferentation pain pain 5.Symptomatic trigeminal 5.Symptomatic trigeminal neuralgia neuralgia 6.Postherpetic neuralgia 6.Postherpetic neuralgia 7.Atypical facial pain 7.Atypical facial pain

Burchiel Burchiel’ ’s s classification classification

TN type 1 TN type 1

• Spontaneous onset, >50% episodic pain

Spontaneous onset, >50% episodic pain TN type 2 TN type 2

• Spontaneous onset, <50% episodic pain

Spontaneous onset, <50% episodic pain Trigeminal Trigeminal neuropathic neuropathic pain pain

• unintentional trigeminal injury / trauma

unintentional trigeminal injury / trauma Trigeminal Trigeminal deafferentation deafferentation pain pain

• Intentional

Intentional deafferentation deafferentation Symptomatic TN Symptomatic TN

• Multiple sclerosis

Multiple sclerosis Postherpetic Postherpetic neuralgia neuralgia

• Trigeminal

Trigeminal Herpes Zoster Herpes Zoster outbreak

• utbreak

Atypical facial pain Atypical facial pain

• Somatoform pain

Somatoform pain disoder disoder

The Delphi study The Delphi study

(J (JÖ

Örns

rns TP and TP and Zakrzewska Zakrzewska JM, 2005) JM, 2005)

Classical trigeminal neuralgia Classical trigeminal neuralgia Atypical trigeminal neuralgia Atypical trigeminal neuralgia

Sharp shooting pain free period Sharp, shooting dull , bur nin g refractory pain free period background dull, aching pain

The Delphi study: TN The Delphi study: TN The problem of terminology The problem of terminology

(J (JÖ

Örns

rns TP and TP and Zakrzewska Zakrzewska JM, 2005) JM, 2005)

Participants Participants Classical TN Classical TN Atypical TN Atypical TN Neurosurgeon 1 Neurosurgeon 1 TN type 1 TN type 1 TN type 2 TN type 2 Neurosurgeon 2 Neurosurgeon 2 TN type 1 TN type 1 TN type 2 TN type 2 Neurosurgeon 3 Neurosurgeon 3 Typical TN Typical TN Atypical TN Atypical TN Neurosurgeon 4 Neurosurgeon 4 Idiopathic TN Idiopathic TN Atypical TN Atypical TN Neurosurgeon 5 Neurosurgeon 5 TN TN TN TN with atypical features with atypical features Neurosurgeon 6 Neurosurgeon 6 Classical TN Classical TN Atypical TN Atypical TN Neurosurgeon 7 Neurosurgeon 7 Typical TN Typical TN NA NA Neurosurgeon 8 Neurosurgeon 8 Typical TN Typical TN Atypical TN / Facial pain Atypical TN / Facial pain Syn Syn. . Neurologist 1 Neurologist 1 Classical TN Classical TN NA NA Neurologist 2 Neurologist 2 TN TN Atypical TN Atypical TN Neurologist 3 Neurologist 3 TN TN Atypical facial pain Atypical facial pain Dentist 1 Dentist 1 Classical TN Classical TN TN TN type 2 type 2 Dentist 2 Dentist 2 Primary TN Trigeminal Primary TN Trigeminal neuropathic neuropathic pain D. pain D. Dentist 3 Dentist 3 Idiopathic TN Idiopathic TN Atypical TN Atypical TN

What would the diagnosis be if What would the diagnosis be if

pain is more nagging aching but there are pain is more nagging aching but there are episodes of sharp pain episodes of sharp pain intermittent but can sometimes be intermittent but can sometimes be constant constant pain same area but tends to go down the pain same area but tends to go down the neck neck provoked by stress, fatigue provoked by stress, fatigue pain in other parts of the body pain in other parts of the body

Chronic idiopathic facial pain Chronic idiopathic facial pain (Atypical facial pain) (Atypical facial pain)

Character Character

– – Nagging, dull, throbbing, sharp, aching Nagging, dull, throbbing, sharp, aching

Severity Severity

– – Varies, mild to severe Varies, mild to severe

Site, radiation Site, radiation

– – Unilateral, bilateral, no anatomical area Unilateral, bilateral, no anatomical area

Duration, periodicity Duration, periodicity

– – Intermittent/constant Intermittent/constant

Chronic idiopathic facial pain Chronic idiopathic facial pain (Atypical facial pain) (Atypical facial pain)

Provoking factors Provoking factors

– – Chewing, stress Chewing, stress

Relieving factors Relieving factors

– – Rest, relaxation Rest, relaxation

Associated factors Associated factors

– – Pain in other areas, Pain in other areas, – – personality changes personality changes – – life events life events

headache irritable bowel pelvic pain itchy skin tinnitus back pain neck pain

Pathophysiology Pathophysiology of TN

• f TN

Symptomatic Symptomatic -

• tumours, AVM

tumours, AVM ( (arteriovenous arteriovenous malformations), multiple malformations), multiple sclerosis sclerosis Idiopathic Idiopathic -

• this could be due to a variety

this could be due to a variety

• f mechanisms and result in different
• f mechanisms and result in different

presentations presentations

The Ignition Theory

Devor Devor et al, et al, Pathophysiology Pathophysiology of

• f

Trigeminal Neuralgia : The Ignition Trigeminal Neuralgia : The Ignition

• Hypothesis. The
• Hypothesis. The Clin
• Clin. J Pain 18:4

. J Pain 18:4-

• 13, 2002

13, 2002

Pain fibre Light touch fibre

The Ignition theory The Ignition theory aaaaaaaaaa aaaaaaaaaa

Ectopic signal

Love S., Love S., Coakham Coakham HB., Trigeminal HB., Trigeminal neuralgia: pathology and neuralgia: pathology and

• pathogenesis. Brain 2002 Mar;
• pathogenesis. Brain 2002 Mar;

124:2347 124:2347-

• 60

60

Investigations Investigations

Haematology Haematology ( (Hb Hb, , folate folate and serum B12) and serum B12) U & E, LFT U & E, LFT Dental radiographs Dental radiographs MRI posterior fossa MRI posterior fossa – – compression, MS compression, MS CT to exclude tumours CT to exclude tumours

Psychosocial and Psychosocial and Q Quality of life uality of life

• McGill Pain Questionnaire (MPQ)

McGill Pain Questionnaire (MPQ)

• Brief Pain Inventory (BPI)

Brief Pain Inventory (BPI)

• Hospital and Anxiety Scale (HAD)

Hospital and Anxiety Scale (HAD)

Acknowledgement Acknowledgement

Royal Thai government Royal Thai government UCB UCB Pharma Pharma Ltd. Ltd. Barts Barts and The London School and The London School

• f Medicine and Dentistry,
• f Medicine and Dentistry,

London, UK London, UK

• Prof. Joanna
• Prof. Joanna Zakrzewska

Zakrzewska Prof.

• Prof. Atholl

Atholl Johnston Johnston

• Dr. Tim
• Dr. Tim Poate

Poate

• Dr. Helen
• Dr. Helen McParland

McParland

• Dr. Stuart
• Dr. Stuart McEachen

McEachen Mrs Mrs Amy Amy Spatz Spatz Mrs Mrs Barbara Barbara Kenway Kenway All TN. patients All TN. patients

ศ ศ นพ นพ สุทธิพันธ สุทธิพันธ จิตพิมลมาศ จิตพิมลมาศ ผศ ผศ ทพญ ทพญ มุขดา มุขดา ศิริเทพทวี ศิริเทพทวี คณะแพทยศาสตร คณะแพทยศาสตร มหาวิทยาลัยขอนแกน มหาวิทยาลัยขอนแกน ภาควิชาชีววิทยาชองปาก ภาควิชาชีววิทยาชองปาก คณะทันต คณะทันต แพทยศาสตร แพทยศาสตร มหาวิทยาลัยขอนแกน มหาวิทยาลัยขอนแกน ภาควิชาวินิจฉัยโรคชองปาก ภาควิชาวินิจฉัยโรคชองปาก คณะทันต คณะทันต แพทยศาสตร แพทยศาสตร มหาวิทยาลัยขอนแกน มหาวิทยาลัยขอนแกน

Thank you for your attentions Thank you for your attentions