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Trigeminal neuralgia

Trigeminal neuralgia, or Tic Douloureux, is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead, and jaw. Trigeminal neuralgia is considered by many to be among the most painful of conditions and has been labeled the "suicide disease," due to the significant numbers of people taking their own lives because they were unable to have their pain controlled with medications or surgery. more...

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An estimated one in 15,000 people suffers from trigeminal neuralgia, although numbers may be significantly higher due to frequent misdiagnosis. It usually develops after the age of 40 and affects women in a 2:1 ratio.

Pathophysiology

The trigeminal nerve is the fifth cranial nerve, a mixed cranial nerve responsible for sensory data such as tactition (pressure), thermoception (temperature), and nociception (pain) originating from the face above the jawline; it is also responsible for the motor function of the muscles of mastication, the muscles involved in chewing but not facial expression. Several theories exist to explain the possible causes of this pain syndrome. Among the structural causes, damage to the myelin sheath of this nerve causes the electrical impulses traveling along it to be erratic or excessive, activating pain regions or deactivating pain inhibitory regions in the brain. The damage may be caused by an aneurysm (an outpouching of a blood vessel) or abnormally coursing artery compressing the nerve, most frequently at the area of its cerebellopontine nerve root; the superior cerebellar artery has been an oft-cited culprit. Two to 4% of patients with TN, usually younger, have evidence of multiple sclerosis, which may damage either the trigeminal nerve or other related parts of the brain. Trigeminal Neuralgia may also be caused by a tumor or a traumatic event such as a car accident. When there is no structural cause, the syndrome is called idiopathic. Postherpetic Neuralgia, which occurs after shingles, may cause similar symptoms if the trigeminal nerve is affected.

Symptoms

The episodes of pain occur paroxysmally, or suddenly, sometimes triggered by common activities or cold exposure, and are said to feel like stabbing electric shocks. Individual attacks affect one side of the face at a time, last several seconds, and may come and go throughout the day, or for periods as long as several months. Three to 5% of cases are bilateral, and attacks may increase in frequency or severity over time. Although trigeminal neuralgia is not fatal, successive recurrences may be incapacitating, and the fear of provoking an attack may make sufferers reluctant to engage in normal activities.

There is a variant of trigeminal neuralgia called, "atypical trigeminal neuralgia." In some cases of atypical trigeminal neuralgia, the sufferer experiences a severe, relentless underlying pain similar to a migraine in addition to the stabbing pains. In other cases, the pain is stabbing and intense, but may feel like burning or prickling, rather than a shock. Sometimes, the pain is a combination of the zaps, the migraine-like pain, and the burning/prickly pain.

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Taking the sting out of trigeminal neuralgia
From Nursing, 3/1/01 by Mosiman, Wendy

ControllingPain

QUESTION: My patient is being treated for trigeminal neuralgia (TN) with 100 mg of carbamazepine (Tegretol) b.i.d. He doesn't have a seizure disorder, so why the anticonvulsant?

ANSWER: Considered an adjuvant analgesic, carbamazepine is the drug of choice for TN, also called tic douloureux. Up to 70% of patients using carbamazepine for TN report pain relief within 48 hours.

Trigeminal neuralgia is a neuropathic pain syndrome that may result from a short circuit of the 5th cranial nerve. According to one theory, a small artery throbbing against the nerve eventually wears off the nerve's insulation, leaving a "bare wire" that's hypersensitive to sensory stimulation.

Something as ordinary as chewing, swallowing, or even feeling a breeze across the face can trigger an attack of pain. Pain may also occur for no apparent reason.

Your patient may describe the pain of TN as excruciating, sudden, sharp, shooting, burning, stabbing, or lancinating. The pain may last several seconds and then recur. It may come and go throughout the day over days or weeks. In some patients, it disappears for months or years, only to recur unexpectedly. These severe, unpredictable pain episodes can evolve into a chronic pain syndrome, resulting in depression and a loss of daily functioning. Even when your patient isn't in pain, fear of the pain returning is never far from his mind.

A sodium channel blocker, carbamazepine inhibits the transmission of excitatory impulses that are perceived as pain. Common adverse reactions are drowsiness, fatigue, dizziness, nystagmus, memory problems, or nausea. To prevent nausea, instruct him to take the medication at mealtime. Adverse reactions may be minimized by increasing the dosage gradually.

Because aplastic anemia and agranulocytosis are potentially serious adverse reactions associated with carbamazepine, obtain a baseline complete blood cell count before starting therapy. Instruct the patient to return for testing after 1 month, 3 months, and every 6 months as directed by his health care provider.

Teach him to report signs and symptoms of infection or bleeding, such as fever, sore throat, rash, mouth ulcers, bruising, and petechial or purpuric hemorrhage. If bone marrow depression is significant, therapy with carbamazepine may be discontinued.

Besides adjuvant medications, opioids and nonopioids may be used to treat neuropathic pain. The use of opioids is controversial, but they may help in some cases. Nonopioid analgesics, such as nonsteroidal anti-- inflammatory drugs and acetaminophen, also may offer pain relief when used in conjunction with other medications.

Copyright Springhouse Corporation Mar 2001
Provided by ProQuest Information and Learning Company. All rights Reserved

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