Download - Trigeminal neuralgia, facial pain in MS
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Trigeminal neuralgia, facial pain in MS
Prof Joanna Zakrzewska
Head of facial pain unit
Eastman Dental Hospital
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Aims and Objectives
Trigeminal neuralgia Diagnosis
Investigations
Medical management
Surgical management
Differential diagnosis
Epidemiology
Patho-
physiology
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Epidemiology TN
Incidence : 4.5 / 100,000
Prevalence : 0.001% - 0.3%
Peak incidence : 50-60 years
Multiple sclerosis (2- 4 % of TN patients)
Hypertension
Stroke
Zakrzewska JM, Hamlyn PJ. In Epidemiology of
Pain. IASP, 1999
Mueller D et al Cephalagia 2011
Pan et al Cephalagia 2011
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Incidence
per 100,000
PY
Hall et al
2006
Dieleman
2008
Koopman et
al 2009
Number 8,268
322 118
Incidence 26.8
28.9 12.6
Changing epidemiology of TN?
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What are other causes of
unilateral episodic facial pain?
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Drangsholt et al 2001
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Dental causes of pain
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Dental Pain – acute/ chronic
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Chronic continuous pain
Unilateral continuous orofacial pain
Yes No
Yes No
• Post herpetic
neuralgia
• Post traumatic
trigeminal pain
• Anesthesia
dolorosa
• Persistent
dentoalveolar
pain
• Referred pain
• Temporomandibular
disorders**
• Persistent orofacial
muscle pain **
Unilateral episodic orofacial pain
Yes No
• Trigeminal
neuralgia
classical (type 1)
• Trigeminal
neuralgia
symptomatic
• Trigeminal
neuralgia +
concomitant pain
( type 2)
• Glossopharyngeal
neuralgia
• Tension type
headache
• Medication
overuse
headache
• Post stroke pain
• Giant cell arteritis *
Cancer pain
Burning mouth
syndrome
Chronic migraine • Trigeminal autonomic
cephalagias
• Episodic migraine *
Persistent idiopathic facial
pain
Zakrzewska BJA 2013
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Temporomandibular Disorders
musculoskeletal
© Zakrzewska
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TMD
© Zakrzewska
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Education- explanation
© Zakrzewska
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Education vs splint
Michelotti JADA 2012;143:47-53 © Zakrzewska
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TMD management
Reassurance, education, relaxation, behaviour changes, intermittent
NSAID
Physiotherapy/ acupuncture, pain coping strategies, reinforce self
care, address psychological distress
Tricyclic antidepressants, cognitive behaviour
therapy, reinforce self care
© Zakrzewska
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© Zakrzewska
Why is the right diagnosis important?
• Epidemiological studies
• Genetic studies
• Recruiting into clinical trials
• Appropriate managements and referrals
• Variants may involve different mechanisms
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Who makes the diagnosis?
HCP making
diagnosis
TN
5287
ATN
189
OFP
857
General medical
practitioner % 36 36 18
Neurologist % 29 30 17
Dentist % 20 15 10
Other specialists % 15 19 55
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Listen to your patient he is
telling you the diagnosis
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The Story of Pain
curiosity to ask “tell me about yourself”
patience to wait for the answer Platt et al 2001
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Stories
• patients tell stories to become who they are
• patient stories are addressed to someone
• the clinician must listen
• the quality of attention is important and
you " have to be caught up” – it is an act of
surrender
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Misery by Rosa Sepple
What are the features of trigeminal neuralgia?
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Character of TN pain
The character of trigeminal neuralgia is very
distinctive and pts will use words such electric
shock, lightening – implies speed as well as severity
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© Zakrzewska
Duration
paroxysmal
pain of abrupt onset and termination
refractory intervals
no background pain
memorable first attack
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© Zakrzewska
Temporal features
Refractory period
Classical TN TN – Type 2, concomitant pain
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Periodicity of TN
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Site and Radiation
Rare
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© Zakrzewska
Provoking factors
R Conelly
Evoked vs spontaneous
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Trigeminal Neuralgia –IASP
“ a sudden, usually unilateral,
severe, brief, stabbing, recurrent
pain in the distribution of one or
more branches of the fifth cranial
nerve”.
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How does TN affect quality of life ?
© Zakrzewska
© R. Sepple
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Associated features Loneliness – isolation – how can
you go to social activities when
you cannot eat,
how can you be intimate when
you cannot bear your face to be
touched
How do you get across the
message that despite looking
normal you have one of the most
suicide pain
Depression is common
Fear of a returning attack is
always with the patients and
psychologist will tell us that this
drives further pain
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Fear
©Eastman
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Tolle et al Pain Practice 2006
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The Patient’s Journey
Through Trigeminal Neuralgia Zakrzewska Padfield May 2014
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Trigeminal Neuralgia
Limonadi et al 2006, Obermann et al 2007
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What is the diagnosis of this
patient ?
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Symptomatic TN
Trigeminal nerve
Tumour
© Zakrzewska
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TG
MS plaque
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vessel
nerve
Neurovascular compression
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Aetiology / Pathophysiology
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© Zakrzewska
Nerve Structure
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Root entry zone, change in nerve
structure
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Love and Coakham, Brain 2001: 124, 2347 – 2360
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Management
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Outcomes
Therapy % pain
relief
Decreased
intensity
frequency
Character of pain
Provoking factors
Side
effects
Beliefs
concerns
Objective
measures
© Zakrzewska
Health utilisation
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Medical management
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Systematic reviews guidelines
www.aan.com
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Which have been evaluated in
Randomised controlled trials - RCTs?
baclofen carbamazepine
valproate lamotrigine epanutin
clonazepam
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Which have been evaluated in RCTs?
gabapentin
pregabalin oxcarbazepine
sumatriptan
leviteracetam
Dextromethorphan
Topiramate
Botox
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Carbamazepine
3 RCT studies (total 160 patients)
NNT 1.7 for >50% pain relief
Maximum 2.4 g / day
Usual dose 200-1,200 mg
NNH 2.6
Multiple drug interactions
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Carbamazepine adverse events
osteoporosis
© Zakrzewska
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Oxcarbazepine
Starting 300 mg bd
Dose range 600-1,200 mg /day
Maximum 2,400 mg/day
Hyponatraemia higher doses
Few drug interactions
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Side effects to anticonvulsants
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Acute management
Fosphenytoin infusion
Sumatriptan 3mg sc
24 patients in RCT
12/24 improved for mean 8 hours
Lidocaine
Injection
Intranasal
IV
Cheshire Fosphenytoin J Pain Sympt 2001
Kania Sumatriptan Head 2006
Han Lidocaine Clin Prac 2008, Kania Br J Aneasth 2006
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Results of RCTs in TN
carbamazepine
oxcarbazepine
lamotrigine
baclofen
gabapentin + LA
pimozide =
tizanidine ?
tocainide
dextromethorphan ?
topiramate ?
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AAN/ EFNS Guideline
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New drug for TN
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Novel Sodium Channel Blocker
CNV1014802 June 2014
• Treatment failure rate
33% CNV1014802 vs 65% placebo
• Decrease in pain severity
55% CNV1014802 vs 18% placebo
• Average reduction in number of paroxysms
60% CNV1014802 vs 12% placebo
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Medications
There is a medicine
you can take
But it’s not the cure
It may make your
drowsy
It may make you sick
There are more pills
to take
And there’s no
miracle fix
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Response to medication
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Insufficient evidence to say
when surgery should be offered
Patients should be given details of all surgical procedures
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Systematic review surgery
3 studies
2 radiofrequency
thermocoagulation
comparing techniques
1 stereotactic surgery
comparing dosages
Cochrane Database of Systematic Reviews 2011, Issue 9
Grading
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Gasserian Ganglion procedures
Radiofrequency rhizotomy
Glycerol rhizotomy
Balloon compression
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Microvascular decompression
Partial sensory rhizotomy
Posterior fossa
Zakrzewska Coakham Current Neurol 2012
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Posterior fossa
Trigeminal nerve
compressed by
superior cerebellar
artery
© Prof H Coakham
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Gamma knife
Radiation doses of 90- 70Gy
Non invasive ablative
procedure
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Complete pain relief after surgery
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5years
% p
rob
ab
ilit
y
radiofrequency thermocoagulation percutaneous glycerol rhizotomy
microvascular decompression gamma knife
© Zakrzewska
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data from 14 studies in 2785 patients
Complications
Mortality
0.2 - 0.5 % for MVD
© Zakrzewska
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Complications
Peripheral ganglion lesions
© Zakrzewska
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Complications
© Zakrzewska
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How 302 patients with MS and TN
compare with 7982 TN only patients ?
Same age and demographics
More constant, bilateral pain
Use wider range of drugs
Undergo more ablative surgery
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Why are there few TN Drug Trials ? Diagnosis strictly clinical
Condition relatively rare
Medications may interfere with other drugs
Medications may take time to work
Spontaneous remission common
Side-effects may take time to appear
Pain very severe: justify using placebo
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AAN/EFNS guidelines
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Patient Information
© Zakrzewska
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Support groups US , UK, Australia , Canada
Web sites : http://www.tna-support.org/
http://www.tna.org.uk/
© Zakrzewska
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Microvascular
decompression
MS
Drug
therapy
Neurovascular compression
Drug therapy
Tumours etc
Idiopathic TN
MRI
Blood tests Symptomatic TN
Ablative procedures Gasserian
ganglion
Gamma knife
Trigeminal neuralgia Primary care
Carbamazepine
Initial good control but now failing
Refer pain clinic
Neurology headache
Neurosurgery Poor
quality of
life
Carbamazepine
Oxcarbazepine
Lamotrigine
Baclofen
Pregablin
Gabapetin
Joint neurosurgery
clinic Psychology
© Zakrzewska
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Choice, Option, Decision
http://www.advancingqualityalliance.nhs.uk/SDM
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References / further
reading
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TN Review BMJ 2014
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Guideline website
www.aan.com
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Resources – e-learning
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TMD & trigeminal neuralgia
http://cks.nice.org.uk/tmj-disorders
http://cks.nice.org.uk/trigeminal-neuralgia
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Educational material
http://www.efic.org/
Year against orofacial pain
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Summary
• Epidemiology provides
clues to aetiology
• Differential diagnosis
• Important diagnostic
features of TN
• Causes
• Investigations
• Management
• References
@ R.Sepple
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Face to face Rosa Sepple
Thank you