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BDS4 Oral Medicine > 27 - Trigeminal neuralgia and trigeminal autonomic cephalalgias > Flashcards

27 - Trigeminal neuralgia and trigeminal autonomic cephalalgias Flashcards

1
Q

What is neuralgia?

A
  • intense stabbing pain, brief but severe
  • pain will extend along course of nerve, which is irritated or damaged
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2
Q

Which cranial nerves can be affected by neuralgia?

A
  • trigeminal
  • glossopharyngeal and vagus
  • nervus intermedius (facial nerve)
  • occipital
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3
Q

Who is typically affected by trigeminal neuralgia?

A
  • F>M
  • predominantly over 60s (younger patients are a cause for concern)
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4
Q

What are the causes of trigeminal neuralgia?

A
  • idiopathic
  • vascular compression of trigeminal nerve (classical of vascular trigeminal conflict)
  • secondary to MS, space occupying lesion
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5
Q

How do you diagnose a vascular trigeminal conflict?

A

MRI

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6
Q

How does trigeminal neuralgia present?

A
  • unilateral maxillary or mandibular division pain (typically not ophthalmic)
  • stabbing pain that last 5-10s
  • triggers include touch, wind, cold, chewing
  • can be paroxysmal or have continuous pain
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7
Q

Define paroxysmal.

A

No pain between episodes

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8
Q

What symptoms differentiate trigeminal neuropathy from trigeminal neuralgia?

A
  • pain on more than one division
  • bilateral pain
  • burning sensation
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9
Q

What symptoms differentiate trigeminal autonomic cephalagia from trigeminal neuralgia?

A

Vasomator component

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10
Q

Describe the appearance of a trigeminal neuralgia patient?

A
  • older patient
  • mask like face due to fear of trigger
  • appearance of excruciating pain, can be unable to speak
  • no obvious precipitating pathology
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11
Q

What red flags are associated with trigeminal neuralgia?

A
  • younger patients under 40
  • sensory deficit in facial region (hearing loss)
  • other cranial lesions
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12
Q

What is the first line drug therapy for trigeminal neuralgia?

A
  • carbamazepine (modified release)
  • oxcarbazepine
  • lamotrigine (slow onset)
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13
Q

What is the second line drug therapy for trigeminal neuralgia?

A
  • gabapentin
  • pregabalin
  • phenytoin
  • baclofen
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14
Q
A
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15
Q

What are the common side effects of carbamazepine?

A
  • blood dyscrasias (thrombocytopenia, neutropenia, pancytopenia)
  • electrolyte imbalances
  • neurological deficits
  • liver toxicity
  • skin reactions
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16
Q

Which drugs can cause hyponatreamia when they interact with carbamazepine?

A
  • PPIs
  • diuretics
17
Q

When is surgery indicated for trigeminal neuralgia?

A
  • not usually recommended if patient is coping with therapeutic management without significant side effects
  • considered when patient is at maximum dose therapeutically
  • considered when younger patient as drug use would be considerable
18
Q

What are the surgical options trigeminal neuralgia?

A
  • microvascular decompression
  • destructive central procedures
  • stereotactic radiosurgery
  • destructive peripheral neurectomies
19
Q

Define allodynia.

A

Pain provoked by a stimulus that typically wouldn’t cause pain

20
Q

What are complications that can occur post-surgery for trigeminal neuralgia?

A
  • local effects from peripheral treatment
  • sensory loss (corneal reflex, general sensation and hearing loss)
  • motor deficits
21
Q

What are the causes of painful trigeminal neuropathy?

A
  • HZV
  • trauma
  • idiopathic
22
Q

What are trigeminal autonomic cephalalgias?

A
  • unilateral head pain (predominantly V1 branch)
  • excruciating
  • associated with cranial parasympathetic autonomic features ipsilateral to headache
23
Q

What are common cranial parasympathetic autonomic features associated with TAC?

A
  • conjunctival injection
  • nasal congestion
  • eyelid oedema
  • ear fullness
  • miosis/ptosis
24
Q

What are TAC also known as?

A
  • cluster headaches
  • suicide headaches
25
Q

What are the different types of TAC?

A
  • cluster headache
  • paroxysmal hemicrania
  • SUNCT
26
Q

Describe a cluster headache.

A
  • pain in orbital and temporal
  • attacks are strictly unilateral with rapid onset and rapid cessation
  • typical duration 15mins to 3hours
  • excruciating pain, patients often restless and agitated
  • prominent ipsilateral autonomic symptoms
  • associated migrainous symptoms include nausea, photophobia, phonophobia
27
Q

Describe the frequency of cluster headaches.

A
  • episodic most common
  • bouts last 1-3 months with at least 1 month remission
  • can be continuous pain between attacks
  • 1-8 attacks a day
28
Q

Describe paroxysmal hemicrania.

A
  • pain in orbital and temporal
  • attacks are strictly unilateral with rapid onset and rapid cessation
  • typical duration 2-30 mins
  • excruciating pain, 50% patients restless and agitated
  • prominent ipsilateral autonomic symptoms
  • associated migrainous symptoms
  • often precipitated by bending or rotating head
29
Q

Describe the frequency of paroxysmal hemicrania.

A
  • chronic most common
  • 2-40 attacks a day
30
Q

What drug therapy is available for cluster headache?

A
  • abortive attack (zolmatriptan or 100% oxygen)
  • abortive bout (lidocaine injection/oral prednisolone)
  • preventive (verapamil/lithium/topiramate)
  • CGRP monoclonal antibodies
31
Q

What drug therapy is available for paroxysmal hemicrania?

A
  • no abortive treatment
  • prophylaxis with indomethacin
  • other alternatives are COX-2 inhibitors, topiramate

BDS4 Oral Medicine (31 decks)

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