Trigeminal Neuralgia

Trigeminal neuralgia is inflammation of

the trigeminal nerve, causing intense
facial pain, paroxysmal, sharp pain and
follow by lacrimation, facial spasm.
It is also known as tic douloureax
because the intense pain can cause
patients to control their face into a
grimace and cause the head to move
away from the pain

Causes trigeminal neuralgia

Most often, the cause of trigeminal
neuralgia is idiopathic,
There are some instances when the
nerve can be compressed by nearby
blood vessels, aneurysms, or tumors.

Causes trigeminal neuralgia

There are inflammatory causes of
trigeminal neuralgia because of systemic
diseases including multiple sclerosis,
sarcoidosis, and Lyme disease.
There also is an association with
collagen vascular diseases including
scleroderma and systemic lupus
erythematosus.

Symptoms of trigeminal neuralgia

Acute onset of sharp,
Stabbing pain to one side of the face.
It tends to begin at the angle of the jaw
and radiate along the junction lines;
Between the ophthalmic branchV1 and
maxillary branch V2, or the maxillary
branch V2 and the mandibular branch V3.

Symptoms of trigeminal neuralgia

The pain is severe and described as an electric
shock.
It may be made worse by light touch, chewing,
or cold exposure in the mouth.
In the midst of an attack, affected individuals
shield their face trying to protect it from being
touched.
This is an important diagnostic sign because
with many other pain syndromes like a
toothache, the person will rub or hold the face
to ease the pain

Symptoms of trigeminal neuralgia

While there may be only one attack of pain, the
person may experience recurrent sharp pain
every few hours or every few seconds.
Between the attacks, the pain resolves
completely and the the person has no
symptoms.
However, because of fear that the intense pain
might return, people can be quite distraught.
.

Symptoms of trigeminal neuralgia

Trigeminal neuralgia tends not to occur when
the person is asleep, and this differentiates it
from migraines, which often waken the person
After the first episode of attacks, the pain may
subside for months or years but there is always
the risk that trigeminal neuralgia will recur
without warning.

The International Headache Society has

established criteria for making the diagnosis
and includes the following
1. Paroxysmal attacks of pain lasting from a
fraction of a second to 2 minutes, affecting 1 or
more divisions of the trigeminal nerve
2. Pain has at least one of the following
characteristics: (1) intense, sharp, superficial or
stabbing; or (2) precipitated from trigger areas
or by trigger factors
3. Attacks stereotyped in the individual patient
4. No clinically evident neurologic deficit
5. Not attributed to another disorder

Triggers

Shaving
Stroking your face
Eating
Drinking
Brushing your teeth
Talking
Putting on makeup
Encountering a breeze
Smiling
Washing your face

Gbr Klinik:
Insidens 4,3 per 100.000 populasi /tahun
Perempuan > laki: 1,17 : 1
Sering pada usia dewasa setelah 40 thn,
ditemukan juga pada anak usia 12 thn.
Nyeri tajam menusuk seperti kesetrum
listrik -> 20-30 detik secara paroksismal.
Unilateral (97%) dapat bilateral
Paling sering pada cabang ke 2 & 3,
Presipitasi mengunyah, menggigit,kontak
pada daerah trigger zone.

Anatomi Transmisi Impuls

Rasa Nyeri

Reseptor nosiseptif miofasial

Serabut aferent urutan pertama (first order)

Nervus Trigeminus
Gangglion Trigeminus

Brainstem setinggi Pons

Cab. Segmen Spinalis
Cervical atas C1 C2

Berakhir TNC

Medulary dorsal horn (MDH)

= Spinal Dorsal Horn (SDH)

Neuron Aferent urutan kedua (second order)

Neuron Aferent urutan ketiga (third order)

Korteks somatosensoris

Korteks somatosensoris sekunder

 Pada saat ini belum ada tes yang

reliabel dalam mendiagnosa
trigeminal neuralgia.
Jadi diagnosa trigeminal neuralgia
dibuat berdasarkan anamnesa
pasien secara teliti dan cermat.
{Zakrzewska,1995}

Treatments and drugs

Medications
Anticonvulsants

Karbamasepin
Phenytoin
Klonazepam
As. Valproat
Baclofen

Antispasmodic agents

treatment for trigeminal

neuralgia
Idiopathic trigeminal neuralgia most often is treated with
good success using a single anticonvulsant medication
such as carbamazepine (Tegretol).
Gabapentin (Neurontin, Gabarone), baclofen and
phenytoin (Dilantin, Dilantin-125) may be used as second
line drugs, often in addition to carbamazepine. In many
patients, as time progresses, carbamazepine becomes
less effective and these drugs can be used in combination
to control the pain.
Should pain persist and medication fail to be effective,
surgery or radiation therapy may be other treatment
options.
Lamotrigine (Lamictal) may be prescribed for multiple
sclerosis patients who develop trigeminal neuralgia.

Non medikamentosa

Surgery
Microvascular decompression
Gamma Knife radiosurgery

Types of rhizotomy include:

Glycerol injection.
Balloon compression.
Radiofrequency thermal lesioning

Complementary and alternative treatments for

trigeminal neuralgia include

Acupuncture
Biofeedback
Vitamin therapy
Nutritional therapy
Electrical stimulation of nerves

New Patient
Carbamazepine (CBZ)

Relief
Continue
CBZ
Reduce
Slowly

Alergic response or
Other severe side effects

Partial Relief

CBZ plus
Phenytoin

Phenytoin or
oxcarbaazepine

Relief
Continue
CBZ plus
Phenytoin

No Relief
CBZ plus
Baclofen

Relief

No Relief

Continue
Phenytoin

Baclofen

Reduce
Slowly

Reduce
Slowly
Relief

No Relief

No Relief

Algoritma terapi medikamentosa trigeminal neuralgia

Relief

Relief

No Relief

No Relief

Continue
CBZ plus
Baclofen

Lamotrigine
or

Relief

Continue
Baclofen

Valproic acid
or
Reduce
Slowly

Reduce
Slowly

Clonazepam
Surgery

Tricyclic
Antidepresant

No Relief

Relief
Continue

Algoritma terapi medikamentosa trigeminal neuralgia