Trigeminal Neuralgia in Emergency Medicine Clinical Presentation

  • Author: J Stephen Huff, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 23, 2012
 

History

History is the most important factor in the diagnosis of typical or classical trigeminal neuralgia (TN). Symptomatic trigeminal neuralgia secondary to intracranial processes may have a different history.

  • Nature of pain
    • Pain is brief and paroxysmal, but it may occur in volleys of multiple attacks.
    • Pain is stabbing or shocklike and is typically severe.
  • Distribution of pain
    • One or more branches of the trigeminal nerve (usually maxillary or mandibular) are involved.
    • Pain is unilateral in classical trigeminal neuralgia.
    • Bilateral pain suggests symptomatic trigeminal neuralgia.[1]
  • Duration of pain is typically from a few seconds to 1-2 minutes.
  • Pain may occur several times a day; patients typically experience no pain between episodes.
  • Trigger points
    • Various triggers may commonly precipitate a pain attack.
    • Light touch or vibration is the most provocative.
    • Activities such as shaving, face washing, or chewing often trigger an episode.
    • Stimuli as mild as a light breeze may provoke pain in some patients.
  • Pain provokes brief muscle spasm of the facial muscles, thus producing the tic.
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Physical

Physical examination findings are normal; in fact, a normal neurologic examination is part of the definition of typical or classic trigeminal neuralgia (TN). Perform a careful examination of the cranial nerves, including the corneal reflex.

  • Be alert to the presence of any abnormality on physical examination. Abnormality suggests that the pain syndrome is secondary to another process.
  • Trigeminal sensory deficits suggest symptomatic trigeminal neuralgia.
  • Remember that patients report pain following stimulation of a trigger point; thus, some patients may limit their examination for fear of stimulating these points.
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Causes

Most patients' conditions are idiopathic, but compression of the trigeminal roots by tumors or vascular anomalies may cause similar pain (see Pathophysiology).

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Contributor Information and Disclosures
Author

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.

Specialty Editor Board

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.

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

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. [Guideline] Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. Oct 2008;15(10):1013-28. [Medline].

  2. Cheshire WP Jr. The shocking tooth about trigeminal neuralgia. N Engl J Med. Jun 29 2000;342(26):2003. [Medline].

  3. Cheshire WP Jr, Wharen RE Jr. Trigeminal neuralgia in a patient with spontaneous intracranial hypotension. Headache. May 2009;49(5):770-3. [Medline].

  4. Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. Oct 7 2008;71(15):1183-90. [Medline].

  5. Knafo H, Kenny B, Mathieu D. Trigeminal neuralgia: outcomes after gamma knife radiosurgery. Can J Neurol Sci. Jan 2009;36(1):78-82. [Medline].

  6. Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. Jan 27 2007;334(7586):201-5. [Medline].

  7. Chole R, Patil R, Degwekar SS, Bhowate RR. Drug treatment of trigeminal neuralgia: a systematic review of the literature. J Oral Maxillofac Surg. Jan 2007;65(1):40-5. [Medline].

  8. Gomez-Arguelles JM, Dorado R, Sepulveda JM, Herrera A, Arrojo FG, Aragon E, et al. Oxcarbazepine monotherapy in carbamazepine-unresponsive trigeminal neuralgia. J Clin Neurosci. May 2008;15(5):516-9. [Medline].

  9. Kubitz PK, Wijdicks EF, Bolton CF. Tic douloureux or "tic dentaire". Neurology. Jan 27 2004;62(2):333. [Medline].

  10. Liu JK, Apfelbaum RI. Treatment of trigeminal neuralgia. Neurosurg Clin N Am. Jul 2004;15(3):319-34. [Medline].

  11. Rasche D, Kress B, Schwark C, Wirtz CR, Unterberg A, Tronnier VM. Treatment of trigeminal neuralgia associated with multiple sclerosis: case report. Neurology. Nov 9 2004;63(9):1714-5. [Medline].

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

 
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Microscopic demonstration of demyelination in primary trigeminal neuralgia. A tortuous axon is surrounded by abnormally discontinuous myelin. Electron microscope, 3, 300 X.
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.
 
 
 
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