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A - BDS4 Oral Medicine > Trigeminal Neuralgia > Flashcards

Trigeminal Neuralgia Flashcards

(58 cards)

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1
Q

What are the 3 categories of pain?

A

nociceptive
neuropathic
nociplastic

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2
Q

What is nociceptive pain?

A

normal physiological response (e.g. trauma, inflammation, non healing injury)

pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors

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3
Q

what is neuropathic pain?

A

lesion or disease of the somatosensory nervous system

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4
Q

what is nociplastic pain?

A

results In increased sensitivity from the altered function of pain related pathways in the periphery and CNS
- triggered by non-nociceptive stimuli

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5
Q

what type of pain is trigeminal neuralgia ?

A

neuropathic

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6
Q

What is trigeminal neuralgia?

A

a disorder characterised by recurrent unilateral brief electric shock pains, abrupt in onset and termination
- limited to the distribution of one or more divisions of the trigeminal nerve
- triggered by innocuous (non-harmful) stimuli
- may develop without apparent cause or be a result of another diagnosed disorder

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7
Q

trigeminal neuralgia - consequences

A

suicide
- 78% of patients had considerable negative thoughts
depression and anxiety
8% have had irreversible and unnecessary dental treatment
47% have been prescribed 3 medications which have been ineffective

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8
Q

name the classifications of trigeminal neuralgia

A

classical
secondary
idiopathic

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9
Q

features of classical trigeminal neuralgia

A

develops without apparent cause other than neurovascular compression
purely paroxysmal / sudden
with concomitant/associated continuous pain

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10
Q

what is secondary trigeminal neuralgia?

A

Trigeminal neuralgia caused by an underlying disease

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11
Q

diseases which may cause trigeminal neuralgia

A

multiple sclerosis
space occupying lesion
other
- skull base deformity
- connective tissue disease
genetic causes of neuropathy

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12
Q

idiopathic trigeminal neuralgia features

A

unilateral or bilateral pain in the distribution of one or more trigeminal nerve branches
- indicative of neural damage but of unknown aetiology
- purely paroxysmal
- with concomitant continuous pain

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13
Q

Classical TN pathophysiology

A

neurovascular conflict of the superior cerebellar artery
compression leads to demyelination
resulting in ectopic firing
- can be observed in asymptomatic patients

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14
Q

idiopathic TN pathophysiology

A

no conflict but unregulated sodium ion inflow resulting in depolarisation

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15
Q

secondary TN pathophysiology

A

pathological process resulting in a reduction in myelin coverage at the pons

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16
Q

Trigeminal neuralgia - how might a patient describe the pain?

A

stabbing
electric shock
severe
memorable first episode
scary
10/10

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17
Q

Trigeminal neuralgia onset

A

spontaneous, sometimes triggers

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18
Q

trigeminal neuralgia site

A

unilateral
- usually 1 branch 60%
- 35% 2 branches
- 4% ophthalmic

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19
Q

Trigeminal neuralgia character

A

sharp/electric shock like pain
- severe

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20
Q

Trigeminal neuralgia - radiates or localised?

A

tends to spread along branch of Trigeminal nerve
- may have a focused starting point

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21
Q

trigeminal neuralgia - associated features

A

distress
suicidal ideation
depression
background pain?
- exclude autonomic features

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22
Q

trinomial neuralgia - time and frequency

A

random, short lived
- up to 2 minutes
- multiple times a day
may have constant less severe background pain

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23
Q

trigeminal neuralgia potentially relieving factors

A

not moving face
avoiding triggers?
medication

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24
Q

trigeminal neuralgia - how it affects sleep

Study These Flashcards
A

may or may not wake up from sleep

25
how can tN affect life quality and mental health?
when attacks become very frequent, patients may become unable to perform daily activities and may avoid eating and communicating for fear of triggering new crisis
26
common TN triggers
eating washing face brushing teeth eating speaking smiling cold wind stress temperature change
27
bilateral TN symptoms
may suggest other disease - perhaps MS
28
Trigeminal neuralgia - red flag features to ask about
sensory motor defects deafness loss of balance optic neuritis history of cranio-facial malignancy bilateral TN systemic symptoms < 30 years of age
29
trigeminal neuralgia - examination
E/O - no abnormalities - exclude TMD intra oral - no abnormalities - exclude acute dental infection - exclude cracked cusps
30
trigeminal neuralgia - how to manage in GDP
obtain accurate diagnosis - exclude TMD/dental pathology consider prescibing carbamazepine - liase with GP for blood monitoring - call OM for advice if unsure on whether it is safe to prescribe Consider LA if patient is in extreme pain Urgent referral to OM or OMFS for definitive advice
31
Prescribing Carbamazepine - considerations
check BNF for interactions care in elderly - increases risk of falls care in those operating heavy machinery or driving or childcare arrange blood monitoring with GP - FBC/U+E/LFT
32
Carbamazepine dose and frequency
100mg tablets 2x a day for 10 days - space out doses as much as possible throughout the day
33
Carbamazepine risks
hyponatraemia - low sodium in the blood - increased with other medications such as bendroflumethiazide falls unsteadiness confusion rash/skin reaction - more common in Han Chinese and Thai populations side effects usually dose dependent - low risks at 100mg 2x daily
34
TN management in secondary care
MRI scan for all patients - space occupying lesion - MS - neurovasuclar conflict - CT considered if MRI contra-indicated Medication optimisation - lowest dose that controls symptoms - carbamazepine - oxcarbazepine - LA in acute episodes - consider gabapentin, prcegablin, baclofen or lamotrigine in refractory cases
35
TN management neurosurgery considerations
may be best long term pain control outcome in suitable cases are medications ineffective? - significant side effects? is there neurovascular conflict? is the patient medically well? does the patient accept the surgical risks?
36
neurosurgical approaches for TN
mircrovasuclar decompression neuro-ablative procedures e.g. balloon compression stereotactic radiosurgery
37
microvascular decompression requirements
there needs to be neurovascular conflict 6 hour operation under GA
38
Microvascular decompression risks
lower chance of numbness several surgical risks
39
Neuro-ablative procedures - outline
shorter procedure - 30 minutes percutaneous needle carefully placed in Meckles cave higher chance of numbness fewer risks short in patient stay
40
why is an MRI taken for trigeminal neuralgia patients?
to exclude underlying disease
41
What are trigeminal autonomic cephalalgias?
group of headache disorders may present similarly to TN but will have autonomic features
42
what are the 4 types of trigeminal autonomic cephalalgias?
cluster headache paroxysmal hemicrania SUNCT/SUNA hemicrania continua
43
Cluster headache signs and symptoms
attacks of severe, strictly unilateral pain which is orbital, supraorbital or temporal or in any combination of these sites lasting 15-180minutes and occurring from once every other day to 8 times a day
44
cluster headache associated symptoms...
ipsilateral conjunctival injection/bloodshot eyes lacrimation nasal congestion rhinorrhoea/runny nose forehead and facial sweating miosis ptosis and/or eyelid oedema and/or restlessness or agitation
45
paroxysmal hemicrania signs and symptoms
attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites lasting 2-30 minutes and occurring several times a day
46
paroxysmal hemicrania associated symptoms
ipsilateral conjunctival injection/bloodshot eyes lacrimation nasal congestion rhinorrhoea forehead and facial sweating miosis ptosis and/or eyelid oedema
47
drug of choice to treat paroxysmal hemicrania
indomethacin
48
what is SUNCT/SUNA?
Short acting , Unilateral. Neuralgiform headache attacks with Conjunctival injection and tearing Short acting. unilateral, neuralgiform headache attacks with cranial autonomic symptoms
49
SUNCT/SUNA signs and symptoms
attacks of moderate, or severe strictly unilateral head pain lasts seconds to minutes , occurring at least once a day
50
SUNCT/SUNA associated symptoms
prominent lacrimation redness of ipsilateral eye
51
Hemicrania continua signs and symptoms
persistant, strictly unilatéral headache - headache is sensitive to indomethacin may have a migrainous component
52
Hemicrania continua associated symptoms
associated with ipsilateral conjunctival injection lacrimation nasal congestion forehead and facial swelling miosis ptosis and/or eyelid oedema and/or restlessness or agitation.
53
Trigeminal autonomic cephalalgias are usually managed by which branch of medicine?
neurology
54
Cluster headache acute management
oxygen triptans lidocaine
55
cluster headache prophylaxis
corticosteroids - short term lithium indomethacin verapamil
56
SUNCT/SUNA medication options
IV lidoncaine, gabapentin, lamotrigine topiramate
57
hemicrania continua medication
indomethacin
58
Trigeminal autonomic cephalalgias - GDP management
exclude dental component if unsure if TN or TAC OM referral TAC best managed by neurology

A - BDS4 Oral Medicine (15 decks)

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