Timothy C. Hain, MD, Chicago IL.
Most recently updated 11/2001
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Trigeminal neuralgia has an incidence of 4-5 per 100,000 of the population. It is characterized by shooting, severe lancinating pain. It is located in the V-2 distribution of the trigeminal nerve, most commonly. Typical symptoms include a shock or jab of pain, lasting 20-30 seconds. Triggers - cold air, motion, eating, sensitive "trigger zones". Often a history of dental procedure -- may be chicken or egg. Sometimes also occurs post-sinus surgery. Possibly related to herpes infection in ganglion. Usually normal examination. Peak incidence is 50-69 y/o. About 1% of persons with MS have trigeminal neuralgia, and 2% of persons with trigeminal neuralgia have MS.
Treatment: Pain relievers -- rarely effective, even narcotics. Carbamazepine (200 BID-TID, check levels at 1 week, get CBC if it works, repeat 2 months and 6 months) and Oxcarbazepine (Trileptal) are effective. One can add baclofen (5 TID, then increase). Phenytoin (Dilantin)less effective, used if allergic to carbamazepine/oxcarbazepine. Also a host of new anticonvulsants are available, such as Gabapentin (Neurontin) and topiramate (Topamax). Response to Oxbamazepine/dilantin may make diagnosis. Some use Depakote/Clonopin. If medical treatment is unsuccessful, can treat with radiofrequency ganglioneurectomy, percutaneous microcompression of trigeminal ganglion, or gamma knife.
Glossopharyngeal neuralgia - neuralgia of 9/10. Ear, tonsil, larynx, posterior tongue location. Triggered by swallowing, foods. May have syncope due to the involvement of the glossopharyngeal nerve in blood pressure control. Incidence is about 1/100 of Trigeminal neuralgia. Brain tumor is found in 15-25%. May be a complication of ear surgery. Similar approach to treatment as trigeminal neuralgia.
Geniculate neuralgia - neuralgia of sensory portion of 7th nerve. Causes ear pain. Can be a part of the Ramsey-Hunt syndrome. May respond to same agents as trigeminal neuralgia. Surgical approach - cut nervous intermedius.
Occipital neuralgia - Some authors are uncertain if this syndrome really exists. Suboccipital pain that radiates to the back of the head. Difficult if not impossible to separate from tension headache, migraine headache, fibromyalgia. Treatment often involves blocks administered by anesthesiology.
Sphenopalatine/vidian neuralgia -- same symptoms as cluster headache and most authors don't think this entity is separate from cluster headache.
Atypical facial pain. Wastebasket syndrome, commonly considered when thinking about neuralgia. Not paroxysmal or triggered, and not in the distribution of any cranial nerve. Does not respond to carbamazepine or close relatives (if it did, it would be classified as neuralgia instead). May respond to antidepressants. Surgery is contraindicated.
(C) Timothy C. Hain, MD