A narrative review published in Headache showed that all aspects of trigeminal neuralgia (TN) need to be explored in order to optimize the exact diagnosis and treatment success.
TN is a rare disease (70 cases per 100,000) that causes excruciating, short-lived, one-sided facial pain. Women are diagnosed more often than men (5.7 vs. 2.5 per 100,000) and the highest incidence occurs between 50 and 60 years of age.
Although reports of pain vary in the literature, patients generally report pain in the maxilla / mandible (33%), mandible (19%), maxilla (17%), eyes / maxilla / mandible (13%), or eyes ( 4%). ) Regions.
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Recently, other subtypes have been associated with TN. The International Classification of Headache Disorders, 3rd edition, defines 3 different types: classical, secondary and idiopathic TN.
Classical or idiopathic TN are either purely paroxysmal or associated with accompanying permanent pain, while classical TN are associated with neurovascular compression and idiopathic TN are not. Secondary participants are attributed to multiple sclerosis (MS), a space-occupying lesion, or other causes.
The diagnostic criterion for a TN includes recurrent unilateral facial pain in more than 1 trigeminal division, severe pain lasting up to 2 minutes, pain that feels like a sharp electric shock and is triggered by harmless stimuli. In addition, the patient’s symptoms should not meet other headache conditions. For diagnosis, patients should undergo a clinical examination and magnetic resonance imaging. No TN-specific diagnostic tests have been developed.
Patients consult family doctors (43.1%), dentists (30.4%), headache specialists (14.7%), ENT specialists (3.9%), and neurosurgeons (3.9%). A TN diagnosis is delayed by an average of 10.8 months after the onset of symptoms.
The initial consultation leads to a misdiagnosis in 42.1% of patients. Common misdiagnoses are migraines, cluster headaches, TMJ dysfunction, tension headaches, glaucoma, otitis, and tonsillitis.
MS has been associated with a 20-fold increased risk of TN, probably caused by demyelination of the trigeminal nerve. TN tends to develop 12 years after onset of MS and in 1.5% to 7.9% of this patient population. MS-associated TNs are more likely to cause bilateral pain (14%) and occur in a younger patient population than classic or idiopathic TNs.
Different tumors were observed to be causative for TN caused by space-occupying lesions. Gamma knife stereotactic radiosurgery has been used successfully to treat benign intracranial tumors, but the associated TN pain does not always go away.
Carbamazepine is highly effective for treating classic TN and some clinicians have extrapolated its effectiveness as a diagnostic test. Newer drugs such as anti-epileptic drugs or sodium channel blockers have been tested for TN and can improve the treatment landscape.
Some patients may be eligible for surgery depending on their age and the severity of their symptoms. However, there is a lack of data to support the effectiveness of this therapeutic pathway.
The review authors concluded: “Research into all aspects of TN – diagnosis, pharmacotherapy, surgery, long-term management prognosis, and natural history – is required. Research should adhere to the ICHD scheme for TN. Improved drugs and thorough research into surgical options and their effectiveness in various subtypes of TN are needed. “
reference
Maarbjerg S, Benoliel R. The Changing Face of Trigeminal Neuralgia – A Narrative Review. A headache. 2021; 61 (6): 817-837. doi: 10.1111 / head.14144
