A Comprehensive Review of Trigeminal neuralgia

 

Manjusha S. Kareppa, Priti B. Savant, Monika S. Jangid, Prajakta N. Acharya

1Assistant Professor, Department of Pharmaceutical Chemistry, Shri Balaji Shikshan Parsarak Mandal College of Pharmacy, Ambajogai - 431517, Maharashtra India.

2Department of Pharmaceutical, Chemistry SKVPM's Sahyadri College of Pharmacy, Methwade 

Dist. Solapur 413307, Maharashtra India.

3Shri Balaji Shikshan Parsarak Mandal College of Pharmacy, Ambajogai - 431517, Maharashtra India.

4Department of Pharmaceutics, Shri Balaji Shikshan Parsarak Mandal College of Pharmacy,

Ambajogai - 431517, Maharashtra India.

*Corresponding Author E-mail: kareppamanjusha2828@gmail.com

 

ABSTRACT:

General practitioners are often the first doctors to see patients with Trigeminal neuralgia (TN). The aim of this article is to provide an up-to-date review of the literature regarding the presentation, classification, diagnosis and treatment of TN. The most painful neurological disease and is often described as "lightning" stuck to the face or a stinging sensation on the face. This condition is almost always unilateral and may involve one or more divisions of the trigeminal nerve. Trigeminal neuralgia, often called tic douloureux. MR imaging, including high-resolution trigeminal sequences, should be performed as part of the diagnostic workup. The most important aspects of TN management are discussed in this review article.

 

KEYWORDS: Trigeminal Neuralgia, Tic Douloureux, Headache, Pain Management, Neurology.

 

 

INTRODUCTION:

The first account of TN is found in the writing of Avicenna in the 11th century, but it was John Fothergill who gave the modern description of TN in this 1773 article on the subject. Trigeminal neuralgia (TN), also known as tic douloureux, is a chronic painful condition characterized by recurrent short episodes of electric shock-like pain affecting the fifth cranial (trigeminal) nerve, which supplies the forehead, lower jaw, and face. This condition is almost always unilateral and may involve one or more divisions of the trigeminal nerve. The trigeminal nerve is the largest of the cranial nerves and is the largest of the cranial nerves and is thought to be one of the factors involved in Causes of migraine.1,2,3

 

It is a highly debilitating disorder that affects basic human functions such as speaking, eating, drinking and touching the face, resulting in a poor quality of life.

 

Epidermological studies show increased anxiety and depression with an increased risk of suicide. This highlights the importance of supporting diagnosis, investigation and treatment.4

 

Etiology:

TN fifth cranial nerve.it is responsible for sensory supply to the face and motor and sensory supply to the masseter muscle. TN starts at the bridge and divides into three branches.5

·       Ocular (v1): supplies the eye, upper lid and forehead.

·       Maxillary (v2): supplies lower lid, cheek, nostril, upper lip and upper gum.

·       Mandibular (v3): supplies the lower lip, lower gum, jaw and masticatory muscle.

 

Jannetta in 1967 first recognized focal compression of the root of TN as the main etiological factor of TN. It is now considered an important cause of TN in 80-90% of cases. The part of the nerve root that is normally compressed is actually inside the CNS tissue. There are the following compressive lesions that can lead to TGN

1. Vestibular schwannomas

2. Meningiomas

3. Epidermoid cyst

 

Classification:

Basedontheetiology:

The international headache society (HIS) has classified trigeminal neuralgia in to two categories according to etiology:

1.     Classical trigeminal neuralgia: In the classical TN there is no cause of the symptoms can be identified other than vascular compression.

2.     Symptomatic trigeminal neuralgia: Symptomatic trigeminal neuralgia has the same clinical criteria, but another under lying cause is responsible for the symptoms.

 

Fig. 1: International classification of headache disorder edition 3 subclassification of TN14.

 

The classification was based on the information provided by the patient, the medical history and includes the following seven diagnostic criteria:

1 and 2 – trigeminal neuralgia type 1 and 2 refers to idiopathic, spontaneous facial pain that is predominantly episodic or constant as in nature.

3.     Neuropathic pain of the trigeminal nerve refers to unintentional injury to the trigeminal nerve during trauma or surgery.

4.     Trigeminal deafferentation pain results from intentional nerve-to-nerve damage by peripheral nerve ablation, gangliolysis, or rhizotomy in an attempt to treat either TN or other associated facial pain.

5.     Symptomatic trigeminal nerve is the result of multiple sclerosis.

6.     Postherpetic TN follows an outbreak of cutaneous herpes zoster in the trigeminal distribution.

7.     The atypical facial pain category is reversed for facial pain secondary to somatoform pain disorder and requires psychological testing for diagnostic confirmation.

 

Based on symptoms:- from a symptomatic point of view, TN is classified as follows- 1] Typical trigeminal neuralgia (tic douloureux) 2] Atypical trigeminal neuralgia6,7

 

Clinical Representation:

·       Some patients are sensitive in certain areas of the face called the trigger zone, which will cause a seizure when touched. These zones that cause an attack when touched. these zones are usually near the nose, lips, eyes or inside the mouth.

·       Over time, the pain tends to worsen with fewer pain-free periods.

·       Recurrent episodes of intense, short-term spasms of pain in the lower part of the lower face and jaw.

·       In most cases, the pain is limited to one side of the face (unilateral).

·       The pain has been likened to a series of "electric shocks" followed by a constant dull ache.

·       The pain often starts and stops quickly.

·       The pain can be triggered by mild tactile stimuli such as brushing the teeth, washing the face, shaving, drinking hot or cold drinks, chewing, talking, blowing the nose, a cold breeze or a light touch to the face.

·       Some episodes may occur without obvious triggers (spontaneously). As a result, episodes may recur during the day.

·       Episodes rarely occur during sleep.

·       Attacks usually stop for a period of time and then return.8

 

Diagnosis:

·       TN can be very difficult to diagnose because there are no diagnostic tests and the symptoms are very similar to other facial pain disorders.

·       Magnetic resonance imaging/angiography (MRI/MRA) is often used to confirm the diagnosis and rule out other possible causes of facial pain.

·       CTN is a clinical diagnosis based on the patient's medical history and a thorough physical examination, especially neurological.

·       Imaging technique can help localize the neurovascular loop area and also find any secondary cause.

·       Most patients with CTN require medical treatment. Medical therapy helps to provide relief from excruciating pain and reduce the frequency and duration of pain as well as associated symptoms.

·       Patients who are resistant or unable to tolerate medications may be candidates for surgical treatment.

·       Neurophysiological recording of trigeminal brainstem reflexes and trigeminal evoked potentials helps detect the lesion.9,10,11,12

 

Treatment:

The European Federation of Neurological Societies and the Quality Standards Subcommittee of the American Academy of Neurology consider carbamazepine (CBZ) to be the drug of choice for the treatment of TN.

 

1. Carbamazepine and oxcarbazepine:

These are first-line treatments for TN and offer meaningful initial pain control in nearly 90% of patients. Although this may not be sustainable in the long term. The benefits of these drugs are offset by side effects that lead to discontinuation in up to 40% of patients. Carbamazepine is known for its metabolic interactions with other drugs, which can be problematic in elderly people with comorbidities.13

 

Contraindications to the use of these agents include cardiac conduction problems and allergic reaction. There is a high degree of cross-reactivity among aromatic anticonvulsants.

 

2. Lamotrigine:

Reported to be useful as adjunctive therapy in a small randomized crossover trial. Lamotrigine can be used in patients who are intolerant to carbamazepine and oxcarbazepine or added to treatment to increase efficacy.

 

3. Gabapectin and pregabalin:

these are 16 randomized controlled trials of gabapectin, all published in chinease, comparing it to carbamazepine. There are no such pathways with pregabalin, but a long-term study suggests it may be effective.14

 

4. Baclofen:

Can help with TN especially in people with multiple sclerosis who may be on spasticity Medicine.15,16,17

 

Aboutthecondition:

There are two nerves- one on each side of the face-that carry the sensation fromthe face and gums to the brain. They are called trigeminal nerve. For example, sensations from the right side of the face are carried by the right trigeminal nerve. Neuralgia means nerve pain. A pulsatile blood vessel compression causes trigeminal neuralgia in a majority of the cases.

 

How Patients Describe the pain due to TN18

A Misunderstood medical condition18

The worst pain experienced by mankind

Trigeminal neuralgia is also known as the ‘SUICIDE DISEASE’ because of the intense pain triggered by talking, eating orevena breeze.

The pain you would not wish even on your enemies.

A study has revealed that 92% of patients Were unaware of the diagnosis.

Pain of 1,000 knives piercing the face

Most of them were treated for dentalor jaw pain, migraine or even psychiatric illness.

A hot ‘chilli bomb’exploding on one side of Your face.

The reason for misdiagnosis is low Awareness of the condition.

 

Surgery:

Medications have proven in effective in treating TN several surgical procedures may help to control the pain recent/advance treatment method/therapy/medicines.

 

REFERENCES:

1.      Trigeminal Neuralgia (fothergill’s disease) in the 17th and 18th centuries . pearce JMS. JNeurolNeurosurg Psychiatry. 2003; 74: 1688. [PMC free article ][Pubmed][Google scholar].

2.      Muhammad H Majeed, Sadaf Arooj, Muhammad Abbas Khokhar, Tamoor Mirza, Ali A aliand Zahid H Bajwa, 2018 Dec. 18.

3.      Headache classification Committee of the international Headache Society(IHS). The international classification of headache disorder, 3rd edition. Cephalgia; an international journal of headache. 2018 Jan; [pubmed PMID: 29368949].

4.      https://www.starpearls.com/articleLibrary/viewarticle/30604

5.      https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6384039

6.      DR. Manjit Matharuand facial pain group, UCL queens quare institute of neurology, London WC1N3BG, UK; Manjit.matharu@nhs.net.

7.      http://www.nhs.uk/ipgmedia/national/migraine%20action/assets/migraine and the trigeminal nerve.pdf

8.      Cruccu G, Di Stefano G, truini A. trigeminal Neuralgia N Engl J Med .2020; 383: 754-62.

9.      Muller D, Obermann M, Yoon M-S, etal. Prevalence of trigeminal neuralgia and persistent idiopathic facial pain: apopulation-based study. Cephalgia 2011; 31: 1542-8.

10.   Blasberg B, Greenberg MS. Orofacial pai. In Greenberg MS, Gick M, editors. Burkets oral medicine diagnosis and treatment, 10th edoition. Hamilton; Ontario BC Decker inc;2003.

11.   Jannetia PJ. Arterial compression of the trigeminalnerve at the pons in patients with trigeminal neuralgia. J. Neurosurg.1967; 26(1): 159-62.

12.   Kraff RM. Trigeminal neuralgia. Amfam physician, 2008; 77(9): 1291-6.

13.   Headache classification sub committee of the international headache society. The international classification of headache disorders 3rd edition. Cephalgia, 2018; 38: 1-211.

14.   The international classification of headache disorders, 3rd edition (beta version) headache classification committee of the international headache society (IHS) https://journal.sagepub.com/ doi/10.1177/0333102413485658.cephalgia.2013;33:629-808[pubmed][Googlescholar].

15.   AAA-EFNS guidelines on trigeminal neuralgia management. Cruccu G, gronseth G, Alksne J, etal. EurJ Neurol. 2008; 15: 1013-1028. [pubmed][googlescholar]

16.   O’C Callaghan L, Floden L, vinikoor-Imler L, etal. Burden of illness of trigeminal neuralgia among patients managedina specialist canter in England J headache pain. 2020; 21: 130.

17.   Zakrzewska JM, Chaudhary Z, Nurmikko TJ, etal. Lamotrigine [Lamictal] in refractory TN; results from a double blind placebo controlled crossover trial. Pain. 1997; 73: 223-30

18.   Kugelberg E, Lindblom U. the mechanism of thrpainin TNJ. Neurol Neurosurg psychiatry. 1959; 22: 36-43.

 

 

 

Received on 24.09.2022         Modified on 06.11.2022        

Accepted on 03.12.2022 ©Asian Pharma Press All Right Reserved

Asian J. Pharm. Tech. 2023; 13(1):51-54.

DOI: 10.52711/2231-5713.2023.00010