Facial Pain

Question 1

A 58-year-old female presents with a 3-week history of right sided facial
pain.

What is a neuralgia?

Answer 1

• Neuralgia is pain that is felt in the distribution of one or more nerves.

Question 2

What are the potential causes of pain in this patient?

Answer 2

• Infective e.g. sinusitis.
• Dental pain e.g. abscess.
• Neuralgia e.g. trigeminal neuralgia, post-herpetic neuralgia.
• Trauma.
• Malignancy.
• Pain radiating from headache e.g. migraine, cluster headache.
• Vascular e.g. temporal arteritis.
• Temporomandibular joint dysfunction.

Question 3

What are the typical features seen in a patient with trigeminal neuralgia?

Answer 3

• Pain occurs in the distribution of one or more branches of the trigeminal nerve.
• The pain is severe and described as shooting, burning or stabbing. Attacks typically last between seconds to minutes.
• The pain is often triggered by talking, eating or the feeling of wind on the patient’s face.
• The patient is usually asymptomatic in between attacks of pain.
• Trigeminal neuralgia is most common in female patients above the
  age of 50.

Question 4

Are there any risk factors associated with trigeminal neuralgia?

Answer 4

Risk factors include:
* Pre-existing MS.
* Age.
* Previous cerebrovascular event.
* Hypertension.
* Charcot-Marie-Tooth disease.
* Intracranial malignancy close to the trigeminal nerve.

Question 5

How would you assess this patient?

Answer 5

History:
* Thorough history to include comorbidities, drug history and social history.

• History of the pain focusing on onset, nature of pain and triggers.
• Effect of the pain on activities of daily living.

Examination:
* Neurological and cranial nerve examinations.

Investigations:
* Basic observations and routine bloods can be used to rule out infective causes.

• Imaging can be considered if intracranial pathology or malignancy is suspected.

Question 6

Based on her history, a diagnosis of trigeminal neuralgia is made.

What are the treatment options for this patient?

Answer 6

Medical:
* Pharmacological therapy is the first line treatment in patients with trigeminal neuralgia, with carbamazepine as the initial agent of choice.
Oxcarbazepine is second line.

• Other drugs that have been used with varying degrees of success include gabapentin, pregabalin, lamotrigine and amitriptyline.

Question 7

What are the treatment options for this patient?

Continued…

Answer 7

Surgical:
* Trigeminal neuralgia can be treated with botox, although mainly if only the ophthalmic branch is affected and in patients where other interventions may be unsuitable.

• Peripheral nerve blockade – a non-invasive technique using alcohol or laser therapy for lysis of the trigeminal nerve branch involved.
• Trigeminal ganglion radiofrequency ablation.
• Microvascular decompression of the trigeminal nerve.
• Gamma knife radiosurgery.

Question 8

What are the complications associated with microvascular decompression surgery?

Answer 8

• Recurrence of symptoms.
• Aseptic meningitis.
• Hearing loss on the affected side.
• Visual defects.
• Facial numbness.
• CSF leak.
• Cerebrovascular event.
• Haemorrhage.
• Death.