Trigeminal Neuralgia in Emergency Medicine Treatment & Management
- Author: J Stephen Huff, MD; Chief Editor: Rick Kulkarni, MD more...
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.
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 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.
Cheshire WP Jr. The shocking tooth about trigeminal neuralgia. N Engl J Med. Jun 29 2000;342(26):2003. [Medline].
Cheshire WP Jr, Wharen RE Jr. Trigeminal neuralgia in a patient with spontaneous intracranial hypotension. Headache. May 2009;49(5):770-3. [Medline].
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].
Knafo H, Kenny B, Mathieu D. Trigeminal neuralgia: outcomes after gamma knife radiosurgery. Can J Neurol Sci. Jan 2009;36(1):78-82. [Medline].
Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. Jan 27 2007;334(7586):201-5. [Medline].
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].
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].
Kubitz PK, Wijdicks EF, Bolton CF. Tic douloureux or "tic dentaire". Neurology. Jan 27 2004;62(2):333. [Medline].
Liu JK, Apfelbaum RI. Treatment of trigeminal neuralgia. Neurosurg Clin N Am. Jul 2004;15(3):319-34. [Medline].
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].
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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