A 62-year-old woman gives a history of a sharp pain lasting for a few seconds whenever she touches the skin over her lower jaw. It is making it difficult for her to carry out daily activities like washing her face or eating. The pain is confined to the left-hand side. Once an episode of pain is complete she can be pain free for about an hour, even if she touches her face in the area affected by the pain. She has been taking paracetamol at regular intervals but this has made no difference to the pain.

The patient gives a classic description including the distribution of pain, trigger zone and a refractory period after stimulation. While Trigeminal neuralgia (classical trigeminal neuralgia; CTN) is highly likely, MRI is obligatory to exclude STN and assess the possibility of DREZ compression.

Trigeminal neuralgia is a disorder characterized by paroxysms of high-intensity facial pain in the distribution of the fifth cranial nerve (Katusic et al., 1990). The treatment options for trigeminal neuralgia include both medical and surgical approaches. Carbamazepine and oxcarbazepine are the first-line pharmacological treatments for trigeminal neuralgia (Szok et al., 2019; Stefano et al., 2021). However, if these drugs fail to provide sufficient pain relief or are poorly tolerated, other medications such as lamotrigine, baclofen, gabapentin, pregabalin, and botulinum toxin type A may be considered (Stefano et al., 2021). Surgical options include microvascular decompression (MVD), which involves relieving vascular compression of the trigeminal nerve (Broggi et al., 2000). Stereotactic radiosurgery (SRS) can also be used for tumor-related trigeminal neuralgia (Kano et al., 2010). In cases where medical therapies and surgical procedures are ineffective, neuromodulation techniques may be considered (Chung & Huh, 2022). It is important to note that the choice of treatment depends on the individual patient’s condition and response to previous treatments (Perszke et al., 2022).

References:

Broggi, G., Ferroli, P., Franzini, A., Servello, D., Dones, I. (2000). Microvascular Decompression For Trigeminal Neuralgia: Comments On a Series Of 250 Cases, Including 10 Patients With Multiple Sclerosis. Journal of Neurology Neurosurgery & Psychiatry, 1(68), 59-64. https://doi.org/10.1136/jnnp.68.1.59 Chung, M., Huh, R. (2022). Neuromodulation For Trigeminal Neuralgia. J Korean Neurosurg Soc, 5(65), 640-651. https://doi.org/10.3340/jkns.2022.0004 Kano, H., Awan, N., Flannery, T., Iyer, A., Flickinger, J., Lunsford, L., … & Kondziolka, D. (2010). Stereotactic Radiosurgery For Patients With Trigeminal Neuralgia Associated With Petroclival Meningiomas. Stereotact Funct Neurosurg, 1(89), 17-24. https://doi.org/10.1159/000321187 Katusic, S., Beard, C., Bergstralh, E., Kurland, L. (1990). Incidence and Clinical Features Of Trigeminal Neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol., 1(27), 89-95. https://doi.org/10.1002/ana.410270114 Perszke, M., Egierska, D., Martynowicz, P. (2022). Trigeminal Neuralgia – Where Are We Today?. J Educ Health Sport, 9(12), 113-127. https://doi.org/10.12775/jehs.2022.12.09.015 Stefano, G., Nurmikko, T., Zakrzewska, J. (2021). Treatment Of Trigeminal Neuralgia: Pharmacological., 89-104. https://doi.org/10.1093/med/9780198871606.003.0009 Szok, D., Tajti, J., Nyári, A., Vécsei, L. (2019). Therapeutic Approaches For Peripheral and Central Neuropathic Pain. BN, (2019), 1-13. https://doi.org/10.1155/2019/8685954