Neuralgia and Trigeminal Neuralgia

Neuralgias

• Trigeminal neuralgia:
  • Characterized by recurring paroxysmal severe pain, brief duration (seconds) in the territory of the trigeminal nerve
  • Spontaneously or initiated by chewing, talking, touching the affected side of the face
  • Unknown aetiology, females affected more than males
  • Treated with pharmacologic therapy (Carbamazepine, Phenytoin, Baclofen) and surgery (in case of failure of medical therapy)
• Glossopharyngeal neuralgia:
  • Unknown cause, equal incidence in both sexes
  • Severe, sudden episodes of pain in the tonsil region (one side only), ipsilateral ear
  • Pain severe for 1-2 hours, recurs daily
  • Treated like trigeminal neuralgia
• Sluder's neuralgia:
  • Intractable pain in the nose, eye, cheek, and lower jaw
  • May be due to lesion of the sphenopalatine ganglion
  • Treated with analgesics, neurectomy

Symptomatic Neuralgias

Intracranial Lesions

• Central lesions:
  • Tumors of the brain stem
  • Multiple Sclerosis
  • Thrombotic lesions
  • Metastasis
  • Occult naso-pharyngeal carcinoma
• Post-herpetic neuralgia:
  • Herpes zoster may affect trigeminal nerve ganglion
  • Vesicular rash covers one division commonly the 1st with severe pain

Extracranial Lesions

• Sinus disease:
  • Infective and neoplastic lesions of the paranasal sinus
  • Facial pain and dental pain, loss of teeth

Migraine

• Criteria for migraine:
  • At least 5 attacks fulfilling the following:
    • Headaches lasting 4 to 72 hours
    • During headache, at least one of the following:
      • Nausea and/or vomiting
      • Photophobia and phonophobia
  • At least 2 of the following criteria:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe intensity
    • Aggravated by physical activity
• Quick Screening Tool for Migraine:
  • Light sensitivity with headache
  • Nausea with headache
  • Decreased ability to function with headache
  • Any 2 out of 3 = Migraine
• Common migraine triggers:
  • Irregular meals
  • Caffeine, chocolate, nuts, bananas, etc.
  • Irregular sleep (particularly excessive sleep)
  • Stress
  • Flickering lights
  • Air travel, change in barometric pressure
  • Menstrual period
  • Medications that may make migraines worse
• The Migraine Lifestyle:
  • Timing of meals, balance of diet
  • Sleep (don't oversleep or undersleep)
  • Caffeine (minimum daily dose)
  • Exercise (the more aerobic exercise the better)
• Treatment:
  • Simple analgesics in mild attacks
  • Moderate and severe attacks are treated with selective Serotonin antagonists during the attack of headache

Other Headaches

• Dental neuralgia:
  • Dental caries
  • Dental extraction
• Temporomandibular joint pain
• Nasal sinus:
  • Acute pain is almost always present
  • Chronic pain is almost always absent
• TMJ:
  • Pain in trigeminal and facial nerve areas
  • Age 15-40, F>M
  • Originates from the jaw joint and is worse with chewing
  • Manage with dental devices and analgesics

Headache Work-up

• Review:
  • HISTORY, HISTORY, HISTORY!
  • CN evaluation
  • Neurological work-up when indicated
  • Blood pressure
  • Refraction
  • Binocular/accommodation testing
  • Sinus evaluation
• Complete ocular health assessment:
  • Visual field testing
• Correct referral to a neurologist
• Consider brain scan if suspect brain tumor, hx of seizures, recent head trauma, significant changes in HA, abnormal neurological signs

Bell's Palsy

• The most common form idiopathic
• Incidence: 1 in 60 or 70 persons
• Pathogenesis unknown
• Clinical Presentation:
  • Onset: abrupt, maximal weakness by 48 hours
  • Pain behind the ear
  • Taste sensation may be lost unilaterally (80% of patients recover)
• Treatment:
  • Protection of the eye during sleep
  • Massage of the weakened muscles
  • Splint
  • Prednisone