(Tic douloureux)

Trigeminal neuralgia is a severe paroxysmal, einschießender facial pain that is caused by a disorder of the fifth cranial nerve. The diagnosis is made clinically. Treatment is usually with carbamazepine or gabapentin, sometimes surgery is necessary.

Trigeminal neuralgia affects mostly adults, especially the elderly.

Trigeminal neuralgia is a severe paroxysmal, einschießender facial pain that is caused by a disorder of the fifth cranial nerve. The diagnosis is made clinically. Treatment is usually with carbamazepine or gabapentin, sometimes surgery is necessary. Trigeminal neuralgia affects mostly adults, especially the elderly. Etiology Trigeminal neuralgia is usually caused by an intracranial artery (z. B. anterior inferior cerebellar artery, ectasia of basilar) Less commonly, through a venous vascular loop compressing the root of the fifth cranial nerve (trigeminal nerve) in its inlet area in the brain stem , Other less common causes include compression by a tumor and occasionally by a plaque in the entrance area of ??the nerve root in multiple sclerosis, but these causes can be distinguished as a rule by means of accompanying sensory and other deficits. Other diseases that cause similar symptoms (eg. As multiple sclerosis) are sometimes regarded as trigeminal neuralgia and sometimes not. It is important to identify the cause. The mechanism is unclear. One theory is that nerve compression causing a local demyelination with the possible consequence of ectopic impulse generation and / or disinhibition central pain pathways involving the spinal trigeminal nucleus. Symptoms and complaints The pain occurs along the innervation of one or more sensitive branches of the trigeminal nerve, most commonly the maxillary nerve. The pain is paroxysmal, lasts from seconds to 2 minutes, but the pain attacks may recur very quickly. The pain is lancinating, distressing and sometimes leads to disabilities. pain frequently is triggered by stimulation of a trigger point in the face (z. B. when chewing, brushing or smile). Sleep on the affected side of the face is often unbearable. Diagnosis Clinical Assessment The symptoms are usually pathognomonic. Thus can be clinically differentiated some other diseases that cause facial pain: Chronic paroxysmal hemicrania (Sjaastad syndrome) is distinguished by a longer (5-8 min) pain attacks and a dramatic response to indomethacin. Post-herpetic pain is divided by a constant period (without convulsions), the typical preceding rash, scarring and a predilection for the Augenast (ophthalmic). Migraine which can cause atypical facial pain, is distinguished by a longer-lasting and often throbbing pain. Neurological examination sizes normal for trigeminal neuralgia. Neurological deficits (usually the loss of facial sensitivity) suggest therefore suggest that the trigeminal neuralgia-like pain-through caused a different disease (eg., Tumor, stroke, plaque in multiple sclerosis, vascular malformation, other lesions N. the compress trigeminal or its paths to the brain stem interrupt). Usually treatment anticonvulsants carbamazepine 200 mg p.o. 3 or 4 times / day is usually effective over a longer period; is begun at 100 mg p.o., the dose is increased to 100-200 mg / day, to control the pain is (maximum daily dose 1200 mg). When carbamazepine is ineffective or harmful, can be attempted one of the following: oxcarbazepine 150-300 mg p.o. 2 times / day gabapentin 300 to 600 mg po 3 times / day (300 mg po once on day 1, 300 mg po 2 times on Day 2, 300 mg po 3 times at 3 day, then increasing the dose to 1200 mg po 3 times / day as needed) Phenytoin 100-200 mg po 2 times / day (starting with 100 mg p.o. 2 times / day, then increase as needed) Baclofen 10-30 mg p.o. 3 times / day (beginning with 5-10 mg p.o. 3 times / day, then increased by about 5 mg / day as needed) amitriptyline 25-150 mg p.o. at bedtime (starting with 25 mg, then increased in 25 mg increments per week as needed) A peripheral nerve block temporarily creates relief. Is the pain despite these measures violently neuroablative treatment strategies must be considered; However, the effect may be limited in time, and the recovery may be followed by recurrent pain that is more severe than the previous episodes of pain. In an access through the posterior fossa a small cushion can be placed which separates the pulsating vascular loops of the trigeminal (called microvascular decompression or Janetta procedure). With a so-called. Gamma Knife radiosurgery can be interrupted as a measure of the proximal trigeminal nerve. An electrolytic or chemical lesion or balloon compression of the trigeminal ganglion may be performed via a percutaneous stereotactically positioned needle. Occasionally, the trigeminal fibers between ganglion and brain stem are severed. Sometimes, as a last resort to relieve persistent pain, the trigeminal nerve is destroyed. Microvascular decompression. Microvascular decompression can relieve pain due to vascular compression of cranial nerve concerned with trigeminal neuralgia, hemifacial spasm or glossopharyngeal. In trigeminal neuralgia, the pressure is relieved by a sponge between the 5th cranial nerve (trigeminal) nerve compression and the artery (Jannetta procedure) is placed. Normally, this method solves the pain, but at about 15% of patients the pain will return.

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