eMedicine Specialties > Neurology > Headache and Pain

Trigeminal Neuralgia: Follow-up

Author: Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Coauthor(s): Gordon H Campbell, MSN, Senior Nurse Practitioner, Department of Mental Health and Neuroscience, Portland Veterans Affairs Medical Center; Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center; Siddharth Gautam, MBBS, Resident Physician, Jersey Neuroscience Institute
Contributor Information and Disclosures

Updated: Aug 21, 2009

Follow-up

Further Inpatient Care

TN is treated on an outpatient basis unless neurosurgical intervention is required.

Further Outpatient Care

  • Patients who experience breakthrough pain may need an increase in the dosage of their medication, if tolerated, or the addition of a second anticonvulsant medication or baclofen. No published data from randomized, prospective, controlled studies are available to guide clinicians regarding multidrug therapy, leaving providers to empiric trials of one agent or another.
  • Neurologists caring for younger patients (<60 y at onset) should consider early neurosurgical consultation, even after a negative MRI of the brain. Surgical procedures occasionally can afford complete relief, delaying the need for anticonvulsant medications for many years, if not permanently.

Inpatient & Outpatient Medications

Outpatient medications customarily used are reviewed in the Medication section.

Deterrence/Prevention

No known methods of deterrence exist.

Complications

  • The chief complication is the adverse effects and toxicity experienced routinely with long-term use of anticonvulsants.
  • Another complication is the waning efficacy over several years of these anticonvulsants in controlling neuralgia, necessitating the addition of a second anticonvulsant, which may cause more drug-related adverse reactions.
  • As noted in the Surgical Care section, both the percutaneous neurosurgical procedures and the microvascular decompression procedures pose risks of long-term complications. Perioperative risks also exist.
  • Patients may have to wait for weeks or months after the operation for relief. Some find relief only for 1-2 years and then must weigh the option of a second operation.
  • Many may need to continue long-term anticonvulsant therapy, although perhaps at lower dosages.
  • Some patients permanently lose sensation over a portion of the face or mouth. Occasionally, patients may suffer jaw weakness and/or corneal anesthesia.
  • The worst complication is anesthesia dolorosa, an intractable facial dysesthesia, which may be more disabling than the original TN.

Prognosis

After an initial attack, the disorder may remit for months or even years. Thereafter the attacks may become more frequent, more easily triggered, disabling, and may require long-term medication.

Patient Education

  • Patients benefit from an explanation of the natural history of the disorder, including the possibility that the syndrome may remit spontaneously for months or even years before they need to consider long-term anticonvulsants. For this reason, some may elect to taper off their medication after the initial attack subsides.
  • Patients should avoid maneuvers that trigger pain. Once the diagnosis is established, advise them that dental extractions do not afford relief, even if pain radiates into the gums.
  • Some may wish to contact the Trigeminal Neuralgia Association (Phone: 609-361-0982).
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Trigeminal Neuralgia (Facial Nerve Pain), Tic Douloureux, and Pain Medications.

Miscellaneous

Medicolegal Pitfalls

  • Failure to properly assess for secondary TN is a major potential pitfall. A careful examination of the cranial nerves and an MRI of the brain, especially in an individual who develops the disorder when younger than 60 years, should protect against missing structural lesions (eg, tumor, cerebral aneurysm, acoustic neuroma).
  • Anticonvulsant medications pose risks of sedation and ataxia, particularly in elderly patients, which may make driving or operating machinery hazardous. They also may pose risks to the liver and the hematologic system. Thus, documentation of patient education about these potential risks is important.
  • Patients also need to understand that medications for TN are only palliative and often are of limited and temporary value. They also must be informed thoroughly of the risks involved with neurosurgical interventions, including anesthesia dolorosa.
 


More on Trigeminal Neuralgia

Overview: Trigeminal Neuralgia
Differential Diagnoses & Workup: Trigeminal Neuralgia
Treatment & Medication: Trigeminal Neuralgia
Follow-up: Trigeminal Neuralgia
References
[ CLOSE WINDOW ]

References

  1. Osler W. The principles and practice of medicine. 8th ed. 1912:191-202.

  2. Penman J. Trigeminal neuralgia. In: Vinkin PJ, Bruyn GW, eds. Handbook of Clinical Neurology. Vol 55. 1968:296-322.

  3. Mauskop A. Trigeminal neuralgia (tic douloureux). J Pain Symptom Manage. Apr 1993;8(3):148-54. [Medline].

  4. Rushton JG, Olafson RA. Trigeminal neuralgia associated with multiple sclerosis. A case report. Arch Neurol. Oct 1965;13(4):383-6. [Medline].

  5. Jensen TS, Rasmussen P, Reske-Nielsen E. Association of trigeminal neuralgia with multiple sclerosis: clinical and pathological features. Acta Neurol Scand. Mar 1982;65(3):182-9. [Medline].

  6. Patten J. Trigeminal neuralgia. In: Neurological Differential Diagnosis. 2nd ed. London: Springer;1996:373-5.

  7. Sands GH. Pain in the face. Headaches in Adults, Annual Course, American Academy of Neurology Annual Meeting. 1994;3:146:130-2.

  8. Fromm GH, Terrence CF, Chattha AS, Glass JD. Baclofen in trigeminal neuralgia: its effect on the spinal trigeminal nucleus: a pilot study. Arch Neurol. Dec 1980;37(12):768-71. [Medline].

  9. Goadsby PJ, Lipton RB. A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases. Brain. Jan 1997;120 (Pt 1):193-209. [Medline].

  10. Türp JC, Gobetti JP. Trigeminal neuralgia versus atypical facial pain. A review of the literature and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Apr 1996;81(4):424-32. [Medline].

  11. Burcheil KJ. Trigeminal neuralgia. In: Conn's Current Therapy. 1999:948-50.

  12. Dalessio DJ. Trigeminal neuralgia. A practical approach to treatment. Drugs. Sep 1982;24(3):248-55. [Medline].

  13. Sist T, Filadora V, Miner M, Lema M. Gabapentin for idiopathic trigeminal neuralgia: report of two cases. Neurology. May 1997;48(5):1467. [Medline].

  14. Khan OA. Gabapentin relieves trigeminal neuralgia in multiple sclerosis patients. Neurology. Aug 1998;51(2):611-4. [Medline].

  15. Solaro C, Lunardi GL, Capello E, et al. An open-label trial of gabapentin treatment of paroxysmal symptoms in multiple sclerosis patients. Neurology. Aug 1998;51(2):609-11. [Medline].

  16. Lunardi G, Leandri M, Albano C, et al. Clinical effectiveness of lamotrigine and plasma levels in essential and symptomatic trigeminal neuralgia. Neurology. Jun 1997;48(6):1714-7. [Medline].

  17. Carrazana EJ, Schachter SC. Alternative uses of lamotrigine and gabapentin in the treatment of trigeminal neuralgia. Neurology. Apr 1998;50(4):1192. [Medline].

  18. Loeser JD. The management of tic douloureux. Pain. Apr 1977;3(2):155-62. [Medline].

  19. Blom S. Trigeminal neuralgia: its treatment with a new anticonvulsant drug (G-32883). Lancet. Apr 21 1962;1:839-40. [Medline].

  20. Raskin NH. Trigeminal neuralgia. 2nd ed. 1988.

  21. Zakrzewska JM, Chaudhry Z, Nurmikko TJ, et al. Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a double-blind placebo controlled crossover trial. Pain. Nov 1997;73(2):223-30. [Medline].

  22. [Best Evidence] He L, Wu B, Zhou M. Non-antiepileptic drugs for trigeminal neuralgia. Cochrane Database Syst Rev. Jul 19 2006;3:CD004029. [Medline].

  23. Parekh S, Shah K, Kotdawalla H. Baclofen in carbamazepine resistant trigeminal neuralgia - a double-blind clinical trial. Cephalalgia. 1989;9 (Suppl 10):392-3.

  24. Fromm GH, Terrence CF. Comparison of L-baclofen and racemic baclofen in trigeminal neuralgia. Neurology. Nov 1987;37(11):1725-8. [Medline].

  25. Sweet WH. Percutaneous methods for the treatment of trigeminal neuralgia and other faciocephalic pain; comparison with microvascular decompression. Semin Neurol. Dec 1988;8(4):272-9. [Medline].

  26. Zakrzewska JM, Thomas DG. Patient's assessment of outcome after three surgical procedures for the management of trigeminal neuralgia. Acta Neurochir (Wien). 1993;122(3-4):225-30. [Medline].

  27. Meglio M, Cioni B. Percutaneous procedures for trigeminal neuralgia: microcompression versus radiofrequency thermocoagulation. Personal experience. Pain. Jul 1989;38(1):9-16. [Medline].

  28. Cappabianca P, Spaziante R, Graziussi G, et al. Percutaneous retrogasserian glycerol rhizolysis for treatment of trigeminal neuralgia. Technique and results in 191 patients. J Neurosurg Sci. Mar 1995;39(1):37-45. [Medline].

  29. Taha JM, Tew JM Jr. Treatment of trigeminal neuralgia by percutaneous radiofrequency rhizotomy. Neurosurg Clin N Am. Jan 1997;8(1):31-9. [Medline].

  30. Kondziolka D, Lunsford LD, Flickinger JC, et al. Stereotactic radiosurgery for trigeminal neuralgia: a multi-institutional study using the gamma unit. J Neurosurg. Jun 1996;84(6):940-5. [Medline].

  31. Kondziolka D, Perez B, Flickinger JC, et al. Gamma knife radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol. Dec 1998;55(12):1524-9. [Medline].

  32. Leksell L. Stereotactic radiosurgery in trigeminal neuralgia. Acta Chem Scand. 1971;37:311-314.

  33. Allam N, Brasil-Neto JP, Brown G, Tomaz C. Injections of botulinum toxin type a produce pain alleviation in intractable trigeminal neuralgia. Clin J Pain. Mar-Apr 2005;21(2):182-4. [Medline].

  34. Gilron I, Booher SL, Rowan MS, et al. A randomized, controlled trial of high-dose dextromethorphan in facial neuralgias. Neurology. Oct 10 2000;55(7):964-71. [Medline].

  35. DMKG study group. Misoprostol in the treatment of trigeminal neuralgia associated with multiple sclerosis. J Neurol. May 2003;250(5):542-5. [Medline].

  36. Aguggia M. Typical facial neuralgias. Neurol Sci. May 2005;26 Suppl 2:s68-70. [Medline].

  37. Bederson JB, Wilson CB. Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia. J Neurosurg. Sep 1989;71(3):359-67. [Medline].

  38. Beniczky S, Tajti J, Timea Varga E, Vecsei L. Evidence-based pharmacological treatment of neuropathic pain syndromes. J Neural Transm. Jun 2005;112(6):735-49. [Medline].

  39. Beydown A, et al. Meta-analysis of comparative trials of oxcarbazepine versus carbamazepine in trigeminal neuralgia. Oxcarbazepine Study Group. Poster presented at the 21st American Pain Society Annual Meeting, Baltimore, Md; Mar 14-17, 2002.

  40. Bowsher D. Trigeminal neuralgia: an anatomically oriented review. Clin Anat. 1997;10(6):409-15. [Medline].

  41. Brisman R. Surgical treatment of trigeminal neuralgia. Semin Neurol. 1997;17(4):367-72. [Medline].

  42. Burchiel KJ. Gamma knife and trigeminal neuralgia. J Neurosurg. Mar 2005;102(3):431-2; discussion 32. [Medline].

  43. Caccia MR. Clonazepam in facial neuralgia and cluster headache. Clinical and electrophysiological study. Eur Neurol. 1975;13(6):560-3. [Medline].

  44. Farago F. Trigeminal neuralgia: its treatment with two new carbamazepine analogues. Eur Neurol. 1987;26(2):73-83. [Medline].

  45. Gilron I, Booher SL, Rowan JS, Max MB. Topiramate in trigeminal neuralgia: a randomized, placebo-controlled multiple crossover pilot study. Clin Neuropharmacol. Mar-Apr 2001;24(2):109-12. [Medline].

  46. Hilton DA, Love S, Gradidge T, Coakham HB. Pathological findings associated with trigeminal neuralgia caused by vascular compression. Neurosurgery. Aug 1994;35(2):299-303; discussion 303. [Medline].

  47. Jorns TP, Zakrzewska JM. Evidence-based approach to the medical management of trigeminal neuralgia. Br J Neurosurg. Jun 2007;21(3):253-61. [Medline].

  48. Kanpolat Y, Ugur HC. Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia. Neurosurgery. Sep 2005;57(3):E601. [Medline].

  49. Product information. Tegretol, Carbamazepine. Novartis Pharmaceuticals Corporation;1998.

  50. Sandell T, Eide PK. Effect of microvascular decompression in trigeminal neuralgia patients with or without constant pain. Neurosurgery. Jul 2008;63(1):93-9; discussion 99-100. [Medline].

  51. Sindrup SH, Jensen TS. Pharmacotherapy of trigeminal neuralgia. Clin J Pain. Jan-Feb 2002;18(1):22-7. [Medline].

  52. Solomon S, Lipton RB. Facial pain. Neurol Clin. Nov 1990;8(4):913-28. [Medline].

  53. Tan LK, Robinson SN, Chatterjee S. Glycerol versus radiofrequency rhizotomy - a comparison of their efficacy in the treatment of trigeminal neuralgia. Br J Neurosurg. Apr 1995;9(2):165-9. [Medline].

  54. Tatli M, Satici O, Kanpolat Y, Sindou M. Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. Acta Neurochir (Wien). Mar 2008;150(3):243-55. [Medline].

  55. Taylor JC, Brauer S, Espir ML. Long-term treatment of trigeminal neuralgia with carbamazepine. Postgrad Med J. Jan 1981;57(663):16-8. [Medline].

  56. Tomson T, Tybring G, Bertilsson L, et al. Carbamazepine therapy in trigeminal neuralgia: clinical effects in relation to plasma concentration. Arch Neurol. Nov 1980;37(11):699-703. [Medline].

  57. Truini A, Galeotti F, Haanpaa M, Zucchi R, Albanesi A, Biasiotta A, et al. Pathophysiology of pain in postherpetic neuralgia: A clinical and neurophysiological study. Pain. Oct 25 2008;[Medline].

  58. Voorhies R, Patterson RH. Management of trigeminal neuralgia (tic douloureux). JAMA. Jun 26 1981;245(24):2521-3. [Medline].

  59. Waltz TA, Dalessio DJ, Copeland B, Abbott G. Percutaneous injection of glycerol for the treatment of trigeminal neuralgia. Clin J Pain. Jun 1989;5(2):195-8. [Medline].

  60. [Best Evidence] Wiffen PJ, McQuay HJ, Moore RA. Carbamazepine for acute and chronic pain. Cochrane Database Syst Rev. 2005;CD005451. [Medline].

  61. Zvartau-Hind M, Din MU, Gilani A, et al. Topiramate relieves refractory trigeminal neuralgia in MS patients. Neurology. Nov 28 2000;55(10):1587-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

trigeminal neuralgia, tic douloureux, TN, facial pain syndrome, facial pain, pain syndrome, carbamazepine therapy, carbamazepine, ICD-9 350-1, atypical facial pain, gamma knife surgery, trigeminal neuralgia symptoms, trigeminal neuralgia causes, trigeminal neuralgia treatment, trigeminal neuralgia medication, trigeminal neuralgia surgery, facial nerve pain, cranial nerve pain

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gordon H Campbell, MSN, Senior Nurse Practitioner, Department of Mental Health and Neuroscience, Portland Veterans Affairs Medical Center
Gordon H Campbell, MSN is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

Siddharth Gautam, MBBS, Resident Physician, Jersey Neuroscience Institute
Disclosure: Nothing to disclose.

Medical Editor

Jorge E Mendizabal, MD, Consulting Staff, Corpus Christi Neurology
Jorge E Mendizabal, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD, Director of Neuro-Ophthalmology, St Helena Hospital
Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.