Trigeminal Neuralgia in Emergency Medicine Treatment & Management

Updated: Nov 22, 2016
  • Author: J Stephen Huff, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
  • Print
Treatment

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. [5, 6]

Coordinate therapy for refractory pain of trigeminal neuralgia with the primary care physician or consultants.

Next:

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. [7] 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 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.
Previous