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Trigeminal Neuralgia Workup

  • Author: Manish K Singh, MD; Chief Editor: Robert A Egan, MD  more...
 
Updated: Oct 22, 2015
 

Approach Considerations

No laboratory, electrophysiologic, or radiologic testing is routinely indicated for the diagnosis of trigeminal neuralgia (TN), as patients with characteristic history and normal neurologic examination may be treated without further workup.

The diagnosis of facial pain is almost entirely based on the patient's history. In most cases of facial pain, no specific laboratory tests are needed. A blood count and liver function tests are required if therapy with carbamazepine is contemplated. Oxcarbazepine can cause hyponatremia, so the serum sodium should be tested after institution of therapy.

Although rarely indicated, appropriate blood work for rheumatic diseases, such as scleroderma (trigeminal neuropathy is reported in up to 5% of patients with this collagen vascular disease) and systemic lupus erythematosus (SLE), should be undertaken in patients with atypical features of facial pain and a systemic presentation of collagen vascular disease. Appropriate blood work includes a sedimentation rate (ESR), antinuclear antibody titer (ANA), double-stranded DNA, anti-Sm antibody, lupus erythematosus cell preparation, and complete blood cell (CBC) count to look for hematologic abnormalities (eg, hemolytic anemia, leukopenia, thrombocytopenia). Particularly in the case of scleroderma, creatinine kinase and aldolase levels may be elevated with muscle involvement. Antibody titers to SCL-86 and SCL-70 may also be present.

In cases with suspected metastatic carcinomatosis, cerebrospinal fluid analysis may confirm the diagnosis. When surgical procedures are contemplated, appropriate and routine preoperative laboratory tests are in order.

In patients older than 60 years, the clinician may first choose to assess the response to a therapeutic trial of medication before considering imaging. A clear relief of pain with carbamazepine or another anticonvulsant confirms the diagnosis of idiopathic trigeminal neuralgia.

Imaging studies are indicated, because distinguishing between classic and symptomatic forms of trigeminal neuralgia is not always clear. Approximately 15% of patients with trigeminal neuralgia (any form) have abnormalities on neuroimaging (computed tomography [CT] scanning and/or magnetic resonance imaging [MRI]). The most common findings are cerebello-pontine angle tumors and multiple sclerosis.

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Magnetic Resonance Imaging

Brain magnetic resonance imaging (MRI) with and without contrast helps to distinguish secondary causes of trigeminal neuralgia (TN) from the idiopathic form. This study is imaging modality of choice and indicated in patients presenting with trigeminal neuralgia when younger than 60 years, principally to exclude tumor. For example, MRI can reveal multiple sclerosis plaques and pontine gliomas.[22] Perform an MRI if atypical features are present. See the image below.

Magnetic resonance image (MRI) with high resolutio Magnetic resonance image (MRI) with high resolution on the pons demonstrating the trigeminal nerve root. In this case, the patient with trigeminal neuralgia has undergone gamma-knife therapy, and the left-sided treated nerve (arrow) is enhanced by gadolinium.

Some physicians recommend elective MRI for all patients to exclude an uncommon mass lesion or aberrant vessel compressing the nerve roots. However, in a published practice parameter, the American Academy of Neurology stated that because of inconsistency of studies, there was insufficient evidence to support or refute the usefulness of MRI or a specific MRI technique to identify vascular anomalies.[23] The recommendation was that, for patients with trigeminal neuralgia, routine imaging may be considered to identify symptomatic trigeminal neuralgia, and this was graded as a level C or possibly effective action.[23]

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Magnetic Resonance Angiography

Magnetic resonance angiography (MRA) can be useful in locating a vascular compression; however, the sensitivity remains low.

Newer special techniques such as high-resolution, 3-dimensional (3-D) MRA (eg, posteroinferior cerebellar artery compresses the trigeminal root) and 3-D spoiled gradient-recalled imaging have been under study, but thus far no consensus to recommend them has been reached.[24] Overall, however, magnetic resonance studies on neurovascular conflicts have shown great variability in outcomes and techniques, with sensitivities as low as 52% and specificity as low as 29%. Therefore, this type of imaging still cannot be recommended as reliable.

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CT Scanning and CT Angiography

Computed tomography (CT) scanning provides poor resolution in the posterior fossa. CT angiography is likewise a consideration, but a lack of large, randomized studies precludes a formal recommendation to routinely perform this test.

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Clinical Neurophysiology Testing

Clinical neurophysiology testing with a blink reflex study may be helpful to demonstrate a lesion of the trigeminus in which a bilateral delay occurs in response to the stimulation on the pathologic side.[25] The blink reflex can clearly help distinguish between the symptomatic form of trigeminal neuralgia and the idiopathic form of trigeminal neuralgia. The sensitivity of this test across studies has been reported as 59-100%, and the specificity has been noted as 93-100%.

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Histologic Features

Although not a diagnostic test, histology reveals focal demyelination as the ultimate lesion in both secondary and idiopathic cases of trigeminal neuralgia. In some instances (eg, tumor) of secondary cases of trigeminal neuralgia, the underlying lesion can be assessed by histology. The most frequent anatomic location is the root entry zone (REZ).

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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 Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Gordon H Campbell, MSN FNP-BC, Neuroscience Nurse Practitioner, Neurology Service, Portland Veterans Affairs Medical Center; Primary Faculty, Clinical Instructor, and Guest Lecturer, Family Nursing Department, Oregon Health Sciences University School of Nursing

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 and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Siddharth Gautam, MBBS Resident Physician, Jersey Neuroscience Institute

Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, 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, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Acknowledgements

Jane W Chan, MD Professor of Neurology/Neuro-ophthalmology, Department of Medicine, Division of Neurology, University of Nevada School of Medicine

Jane W Chan, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

James R Couch, MD, PhD, FACP Professor of Neurology, University of Oklahoma Health Sciences Center

Disclosure: Nothing to disclose.

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Andrew W Lawton, MD Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association

Disclosure: Nothing to disclose.

Marc E Lenaerts, MD, FAHS Staff Neurologist, Mercy Medical Group; Associate Clinical Professor of Neurology, Department of Neurology, University of California, Davis, School of Medicine

Marc E Lenaerts, MD, FAHS is a member of the following medical societies: American Academy of Neurology, American Headache Society, and International Headache Society

Disclosure: Nothing to disclose.

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.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Tom Scaletta, MD Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

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Illustration depicting the trigeminal nerve with its 3 main branches
Microscopic demonstration of demyelination in primary trigeminal neuralgia. A tortuous axon is surrounded by abnormally discontinuous myelin. (Electron microscope; 3300×).
Magnetic resonance image (MRI) with high resolution on the pons demonstrating the trigeminal nerve root. In this case, the patient with trigeminal neuralgia has undergone gamma-knife therapy, and the left-sided treated nerve (arrow) is enhanced by gadolinium.
Microvascular decompression (Jannetta procedure) used to treat trigeminal neuralgia. The anteroinferior cerebellar artery and the trigeminal nerve are in direct contact. Courtesy of PT Dang, CH Luxembourg
Table 1. Characteristic Features of 3 Common Craniofacial Pains
Condition Male:Female Ratio Age of onset, y Localization Accompanying Symptoms Attack Duration Cycles Provocation
Trigeminal neuralgia 1:2 >50 Unilateral None Seconds Month intervals Trigger zones
Cluster headache 31:1 30-40 Always unilateral Horner syndrome, conjunctival injection, epiphora 15-180 minutes Clusters with weeks to months intervals Nocturnal attacks
Migraine 1:1 10-20 Variable Photophobia, phonophobia, gastrointestinal symptoms 4-72 hours Days to weeks intervals Variable
Table 2. Distinguishing Features Between Trigeminal Neuralgia and Atypical Facial Pain
Feature Trigeminal Neuralgia Atypical Facial Pain
Prevalence Rare Common
Main location Trigeminal area Face, neck, ear
Pain duration Seconds to 2 minutes Hours to days
Character Electric jerks, stabbing Throbbing, dull
Pain intensity Severe Mild to moderate
Provoking factors Light touch, washing, shaving, eating, talking Stress, cold
Associated symptoms None Sensory abnormalities
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