UMEM Educational Pearls

Title: The Painful Twitch - Trigeminal Neuralgia

Category: Neurology

Keywords: trigeminal neuralgia, TN, tic douloureux, neuropathic facial pain (PubMed Search)

Posted: 8/26/2020 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

Trigeminal neuralgia is diagnosed by:
- Pain in 1 or more divisions of the trigeminal nerve
- Paroxysms of pain that are sudden, intense, usually few seconds in duration
- Pain triggered by innocuous stimuli in the trigeminal nerve territory (91-99% patients)
24-49% of patients experience continuous or long-lasting pain
Exam may reveal forceful contraction of the facial muscles during a paroxysm (tic convulsif)
Causes include:
- Intracranial vascular compression of the trigeminal nerve root (most common)
- Multiple sclerosis, cerebellopontine angle tumor
- Idiopathic (10% of cases)
Carbamazepine and oxcarbazepine are first-line treatments
- They may be poorly tolerated due to side effects including dizziness, diplopia, ataxia, CNS depression, and hyponatremia
- They also have limited efficacy on continuous pain
Acute exacerbations may warrant admission for hydration, acute pain control, and titration of antiepileptic drugs
- Botulinum toxin A was recently added as a treatment option

Bottom Line: New onset trigeminal neuralgia needs workup for its etiology. Carbamazepine and oxcarbazepine can be effective for symptom management though continuous or long-lasting pain exacerbations are difficult to treat.

References

Cruccu G, Di Stefano G, Truini A. Trigeminal neuralgia. N Engl J Med. 2020;383(8):754-62.
Bendtsen L, Zakrzewska JM, Heinskou TB, et al. Advances in diagnosis, classification, pathophysiology, and management of trigeminal neuralgia. Lancet Neurol. 2020;19(9):784-96.

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