Trigeminal Neuralgia in Emergency Medicine Treatment & Management

  • Author: J Stephen Huff, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 24, 2010
 

Emergency Department Care

Care in the ED is generally limited to correct identification of trigeminal neuralgia (TN), consideration of alternative diagnosis, pain relief, and coordination of follow-up care.

  • Because of the time-limited character of pain with typical trigeminal neuralgia, patients often do not present to the ED for pain medication.
  • In some patients, the typically episodic pain becomes constant or so frequent as to be debilitating.
    • Infusion of phenytoin is reportedly successful in interrupting such episodes, but the value of this therapy is anecdotal.
    • Coordinate therapy for refractory pain of trigeminal neuralgia with the primary care physician or consultants.
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Consultations

Patients with a typical history and normal physical examination may be referred to their primary care physician for further care. Neurologic or neurosurgical consultations may be helpful, particularly if atypical features are present.

  • Referral to a neurologist may be helpful if the diagnosis is in doubt.
  • Referral to a neurosurgeon may be indicated for patients whose conditions prove refractory to medical treatment. Percutaneous radiofrequency ablation of a portion of the trigeminal ganglion is commonly performed, as are anesthetic blocks of the trigeminal ganglion. Gamma knife radiosurgery is used at some centers.[4] Less commonly performed is decompression of the region of trigeminal root entry of impinging vascular structures. An MRI of a patient who has undergone gamma knife surgery is shown below. MRI with high resolution on the pons demonstratingMRI 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.
  • Comprehensive pain center follow-up care may be helpful.
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Contributor Information and Disclosures
Author

J Stephen Huff, MD  Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center

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, Joan and Sanford Weill Medical College at Cornell University; 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  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Tom Scaletta, MD  Chairperson, 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 

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

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

  3. 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].

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

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

  6. 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].

  7. 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].

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

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

  10. 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].

  11. 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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