eMedicine Specialties > Ophthalmology > Neurologic Disorders

Trigeminal Neuralgia: Differential Diagnoses & Workup

Author: Marc E Lenaerts, MD, Clerkship Director, Assistant Professor, Department of Neurology, University of Oklahoma
Coauthor(s): James R Couch, MD, PhD, FACP, Professor of Neurology, University of Oklahoma Health Sciences Center
Contributor Information and Disclosures

Updated: Mar 17, 2006

Differential Diagnoses

Other Problems to Be Considered

The differential diagnosis will be most critical with related trigeminal autonomic cephalgias, such as cluster headache and chronic paroxysmal hemicrania.

Cluster headache: Pain is not restricted to a branch of the trigeminal nerve but is periocular, lasts longer (15-120 min), is not triggerable, is accompanied by prominent autonomic symptoms, and usually has fewer episodes a day.

Raeder syndrome: Ophthalmoparesis is present.

Atypical facial pain: In addition to pain that is of vague localization and long duration (usually chronic and daily), psychiatric disturbances are associated.

SUNCT: Pain is of longer duration (2-3 min), and prominent autonomic symptoms (eg, lacrimation, rhinorrhea) are associated.

Tolosa-Hunt syndrome: Pain is of longer duration but not triggerable.

Dental abscess, sinusitis, and sinusal adenocarcinoma are possible differential diagnoses.

Workup

Laboratory Studies

  • No routine laboratory studies are performed in the initial workup. Laboratory work is not frequently helpful but should be directed by the clinical context.
  • An inflammatory disease might be supported by an elevated erythrocyte sedimentation rate (ESR). Lyme titers can be demonstrated by serology.
  • Cerebrospinal fluid (CSF) may confirm metastatic carcinomatosis.

Imaging Studies

  • Imaging studies are indicated because distinguishing between idiopathic and secondary forms of trigeminal neuralgia is not always clear.
  • CT scan provides a poor resolution in the posterior fossa.
  • MRI is the imaging modality of choice. It can reveal MS plaques and pontine gliomas.
  • Magnetic resonance angiography (MRA) can be useful in locating a vascular compression; however, the sensitivity remains low.
  • Newer techniques, with enlarged and/or tridimensional views of the pontine area, can demonstrate a neurovascular conflict (eg, posteroinferior cerebellar artery compresses the trigeminal root). See Image 2.
  • Conventional angiogram is only useful if a vascular malformation is suspected, but it fails to directly demonstrate the relationship with the nerve.

Other Tests

  • 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. The blink reflex can clearly help distinguish between the symptomatic form and the idiopathic form of the syndrome.

Histologic Findings

Although not a diagnostic test, histologic findings reveal focal demyelination as the ultimate lesion in both secondary and idiopathic cases. In secondary cases, the underlying lesion can be assessed by histology in some instances (eg, tumor).

More on Trigeminal Neuralgia

Overview: Trigeminal Neuralgia
Differential Diagnoses & Workup: Trigeminal Neuralgia
Treatment & Medication: Trigeminal Neuralgia
Follow-up: Trigeminal Neuralgia
Multimedia: Trigeminal Neuralgia
References
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References

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Further Reading

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Keywords

tic douloureux

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Contributor Information and Disclosures

Author

Marc E Lenaerts, MD, Clerkship Director, Assistant Professor, Department of Neurology, University of Oklahoma
Marc E Lenaerts, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Merck and OrthoMcNeil Neurologics Honoraria Speaking and teaching

Coauthor(s)

James R Couch, MD, PhD, FACP, Professor of Neurology, University of Oklahoma Health Sciences Center
James R Couch, MD, PhD, FACP is a member of the following medical societies: American Academy of Neurology, American Geriatrics Society, American Headache Society, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, American Stroke Association, and United Council of Neurologic Subspecialties, Certification in Headache Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
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.

Managing Editor

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.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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