QuestionSBA
QuestionChoice
Lamotrigine is used as a tertiary line therapy for trigeminal neuralgia, although its evidence is limited, with a recent Cochrane review suggesting it has no efficacy in its management. Carbamazepine is the only therapy with proven efficacy in randomised controlled trials
33082
e
Lamotrigine
QuestionChoice
While duloxetine is used in other forms of neuropathic pain, there is no evidence for its use in trigeminal neuralgia
33079
b
Duloxetine
QuestionChoice
Carbamazepine is currently the first line for the treatment of trigeminal neuralgia. It acts by inhibiting voltage-gated sodium channels, thereby reducing excitability of neural membranes. It is the only therapy with proven efficacy in randomised controlled trials in treating trigeminal neuralgia
33078
a
Carbamazepine
QuestionChoice
Gabapentin is used as a tertiary line therapy for trigeminal neuralgia, although there is little evidence of its use in randomised controlled trials. Carbamazepine is the only therapy with proven efficacy in randomised controlled trials
33081
d
Gabapentin
QuestionChoice
While amitriptyline is used in other forms of neuropathic pain, there is no evidence for its use in trigeminal neuralgia
33080
c
Amitriptyline
QuestionComment
Isn’t it more common in older people, also why is cranial nerve exam normal?
22382
User
subscriber
Viral Vitamin
QuestionComment
does anyone know why you treat trigeminal neuralgia differently from other forms of neuropathic pain ?
25284
User
subscriber
Amy
Concept
Chapter
# Summary

Trigeminal neuralgia is a chronic neurological disorder characterised by severe shooting or stabbing pain in the distribution of one or more divisions of the trigeminal nerve. Pain can be triggered by light touch, eating, or wind blowing on the patient's face. Aetiology can be either primary or secondary (secondary to an underlying intracranial lesion). Diagnostic investigations primarily revolve around excluding other possible causes of facial pain. Management strategies include both medical (carbamazepine as the first-line drug) and surgical treatments.

# Definition

Trigeminal neuralgia is a chronic pain condition characterized by severe, sudden, and brief bouts of shooting or stabbing pain that follow the distribution of one or more divisions of the trigeminal nerve, affecting the patient's facial region.

# Epidemiology

Trigeminal neuralgia typically affects adults over the age of 50, with a higher prevalence in women. The incidence of trigeminal neuralgia is approximately 4-5 per 100,000 people annually.

# Aetiology

Trigeminal neuralgia can be classified as either primary (idiopathic) or secondary, with the latter being associated with identifiable etiological factors. Known causes include:

- Malignancy: can lead to nerve compression or infiltration, resulting in pain
- Arteriovenous malformation: abnormal, tangled blood vessels can compress the trigeminal nerve
- Multiple sclerosis: demyelination in this condition can affect the trigeminal nerve
- Sarcoidosis: granulomatous lesions can affect the trigeminal nerve
- Lyme disease: infection and subsequent inflammation can affect the trigeminal nerve

# Signs and Symptoms

- Unilateral facial pain that is sudden, severe, and brief. 
- The pain is often described as shooting or stabbing,
- Triggered by lightly touching the affected side of the face, eating, or wind blowing on the face.

Neurological examination in these patients is typically normal.

# Differential Diagnosis

Differential diagnoses of trigeminal neuralgia include:

- Post-herpetic neuralgia: presents with persistent pain following the resolution of a shingles rash. The pain is typically continuous, aching, burning, or throbbing.
- Temporomandibular joint disorders: presents with pain in the jaw joint and muscles controlling jaw movement. Other symptoms include difficulty chewing and joint locking.
- Giant cell arteritis: presents with headache, scalp tenderness, jaw pain, and visual symptoms. Other symptoms include fatigue, loss of appetite, and fever.
- Cluster headache: presents with severe, unilateral headaches occurring in clusters. Other symptoms include eye watering, nasal congestion, and ptosis on the affected side.
- Trigeminal autonomic cephalalgias (TACS):a group of primary headache disorders characterised by intense unilateral pain with autonomic symptoms. Usually spontaneous and not triggered by touch

# Investigations

Trigeminal neuralgia is largely a clinical diagnosis, but investigations may be performed to rule out other causes of facial pain. 

Neuroimaging such as MRI can be used to exclude secondary causes, including tumours or vascular compression. 

# Management

Management of trigeminal neuralgia can be both medical and surgical. 

- Medical management typically includes;
  - **Carbamazepine** (first-line treatment)
  - Phenytoin
  - Lamotrigine
  - Gabapentin
- Surgical management includes;
  - Microvascular decompression: a procedure to remove or relocate blood vessels that are in contact with the trigeminal root
  - Treatment of the underlying cause: such as removing a tumour or addressing an arteriovenous malformation
  - Alcohol or glycerol injections: used to damage the trigeminal nerve and reduce pain signals

# References

[Click here for NICE CKS on trigeminal neuralgia](https://cks.nice.org.uk/topics/trigeminal-neuralgia/)

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Trigeminal neuralgia
Topic
34
Neurology
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Carbamazepine is the first-line treatment for trigeminal neuralgia, effectively reducing neural excitability by inhibiting voltage-gated sodium channels.
A 26-year-old woman presents to the GP with paroxysmal allodynia and shock-like pains of the right side of her face. Cranial nerve examination and otoscopy are unremarkable.

Which of the following is the best next step in the management of this patient?
a