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 Berakhir TNC Medulary dorsal horn (MDH)

Cervical atas C1 – C2 = 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 Partial Relief Alergic response or

Other severe side effects

Continue CBZ plus

CBZ Phenytoin or
Phenytoin oxcarbaazepine
Reduce
Slowly Relief No Relief Relief No Relief

Continue CBZ plus

CBZ plus Continue
Baclofen Phenytoin Baclofen
Phenytoin

Reduce Reduce
Slowly Slowly

Relief No Relief No Relief Relief

Algoritma terapi medikamentosa trigeminal neuralgia

Relief No Relief No Relief Relief

Continue
Lamotrigine Continue
CBZ plus
or Baclofen
Baclofen
Valproic acid
or
Reduce Reduce
Slowly Clonazepam Slowly

Surgery Tricyclic
Antidepresant

No Relief Relief

Continue

Algoritma terapi medikamentosa trigeminal neuralgia