trigeminal neuralgia, autonomic headache and migraine

Question 1

What is neuralgia?

Answer 1

An intense stabbing pain
Usually brief but severe
Pain extends along the course of the affected nerve
Usually caused by irritation or damage to a nerve

Question 2

Give 4 examples of nerves affected in cranial neuralgias

Answer 2

Any from:
- trigeminal
- glossopharyngeal
- vagus
- nervous intermedius
- occipital

Question 3

What is the incidence of TN?

Answer 3

Affects 4.3 in 100,000 people
Female:male ratio is 5.9:3.4

Question 4

What are the causes of TN?

Answer 4

Idiopathic
Classical - vascular compression of the trigeminal nerve
Secondary:
- multiple sclerosis
- space-occupying lesions
- others eg connective tissue disease, skull-base bone deformity

Question 5

How does TN usually present?

Answer 5

Unilateral maxillary or mandibular division pain - more common than ophthalmic division
5-10 seconds duration
Purely paroxysmal (uncontrollable and sudden) or with continuous pain
Usually older patient

Question 6

What are the triggers of TN?

Answer 6

Cutaneous
Wind and cold
Touch
Chewing

Question 7

Describe the acute spasms of pain in TN

Answer 7

May be more than one division
May be bilateral
May have a burning component
May have a vasomotor component

Question 8

What are the red flags of TN?

Answer 8

Younger patients (<40)
Sensory deficit in facial region - hearing loss
Other cranial nerve lesions
Always test cranial nerves to identify sensory deficit - pts all now get an MRI

Question 9

What is the first line drug therapy for TN?

Answer 9

Carbamazepine - modified release
Oxycarbazepine
Lamotrigine - slow onset of action

Question 10

What is the second line drug therapy for TN?

Answer 10

Gabapentin
Pregabalin
Phenytoin
Baclofen

Question 11

How is TN managed?

Answer 11

Patient should be responsive to carbamazepine if they can tolerate it
Pain often difficult to control first thing in the morning
Pain diary helpful to identify modifications necessary to therapy
Maximise effects of drugs whilst minimising size effects
Patients can be responsive to LA

Question 12

What are the side effects of carbamazepine?

Answer 12

Blood disorders - thrombocytopenia, neutropenia, pancytopenia
Electrolyte imbalances (hyponatreamia)
Neurological deficits - Paraesthesia, vestibular problems
Liver toxicity
Skin reactions (potentially life threatening)

Question 13

When is surgery considered for TN?

Answer 13

When approaching maximum tolerable medical management even if pain is controlled
In younger patients with significant drug use

Question 14

What are the surgical options for TN?

Answer 14

Microvascular decompression (MVD) - preferred treatment where possible
Stereotactic radiosurgery
Destructive central procedures
Destructive peripheral neurectomies

Question 15

What are the complications of TN surgery?

Answer 15

Sensory loss - corneal reflex, general sensation and hearing loss
Motor deficits
These may be reversible or irreversible

Question 16

What are the causes of painful trigeminal neuropathy?

Answer 16

Herpes Zoster Virus
Trauma
Idiopathic

Question 17

What are the characteristics of painful trigeminal neuropathy?

Answer 17

Pain localised to the distributions of the trigeminal nerve
Commonly describes as burning or squeezing like pins and needles
Primary pain usually continuous or near continuous
Commonly accompanied by allodynia and sensory deficits

Question 18

What is allodynia?

Answer 18

Pain due to a stimulus that does not normally provoke pain

Question 19

What are trigeminal autonomic cephalalgias?

Answer 19

Unilateral head pain - predominantly from V1
Very severe, excruciating pain
Include cluster headache, paroxysmal hemicrania and SUNCT

Question 20

For cluster headache, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?

Answer 20

1-8 daily
15-180 minutes
Sharp, throbbing pain
Very severe pain
70%

Question 21

For paroxysmal hemicrania, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?

Answer 21

1-40 daily
2-30 minutes
Sharp, throbbing pain
Very severe pain
45%

Question 22

For SUNCT, what is the attack frequency, duration of attack, pain quality, pain intensity and circadian periodicity?

Answer 22

3-200 daily
5-240 seconds
Stabbing, burning pain
Very severe pain
Circadian periodicity is absent

Question 23

What is aura?

Answer 23

Neurological symptoms experienced before the onset of a headache

Question 24

What is cluster headache known as and where is the pain usually?

Answer 24

Suicide headache
Pain mainly orbital and temporal

Question 25

What are the symptoms of cluster headache?

Answer 25

Migraine symptoms - tiredness, yawning
Nausea
Vomiting
Photophobia (abnormal sensitivity to light)
Aura in 14% of patients

Question 26

Where is the pain mainly for paroxysmal hemicrania?

Answer 26

Pain is mainly orbital and temporal
Attacks strictly unilateral

Question 27

What drugs are used to treat cluster headache?

Answer 27

Abortive (attack) - sumatriptan or zolmatripan and 100% oxygen
Abortive (bout) - occipital lidocaine, oral prednisolone
Preventative - lithium, verapamil
CGRP - monoclonal antibodies

Question 28

What drugs are used to treat paroxysmal hemicrania?

Answer 28

No abortive treatment
Prophylaxis with indomethacin
Alternatives - COX-II inhibitors, topiramate