Advances in diagnosis and treatment of trigeminal neuralgia

Abstract

Various drugs and surgical procedures have been utilized for the treatment of trigeminal neuralgia (TN). Despite numerous available approaches, the results are not completely satisfying. The need for more contemporaneous drugs to control the pain attacks is a common experience. Moreover, a number of patients become drug resistant, needing a surgical procedure to treat the neuralgia. Nonetheless, pain recurrence after one or more surgical operations is also frequently seen. These facts reflect the lack of the precise understanding of the TN pathogenesis. Classically, it has been related to a neurovascular compression at the trigeminal nerve root entry-zone in the prepontine cistern. However, it has been evidenced that in the pain onset and recurrence, various neurophysiological mechanisms other than the neurovascular conflict are involved. Recently, the introduction of new magnetic resonance techniques, such as voxel-based morphometry, diffusion tensor imaging, three-dimensional time-of-flight magnetic resonance angiography, and fluid attenuated inversion recovery sequences, has provided new insight about the TN pathogenesis. Some of these new sequences have also been used to better preoperatively evidence the neurovascular conflict in the surgical planning of microvascular decompression. Moreover, the endoscopy (during microvascular decompression) and the intraoperative computed tomography with integrated neuronavigation (during percutaneous procedures) have been recently introduced in the challenging cases. In the last few years, efforts have been made in order to better define the optimal target when performing the gamma knife radiosurgery. Moreover, some authors have also evidenced that neurostimulation might represent an opportunity in TN refractory to other surgical treatments. The aim of this work was to review the recent literature about the pathogenesis, diagnosis, and medical and surgical treatments, and discuss the significant advances in all these fields.

Pharmaceutical Management of Trigeminal Neuralgia in the Elderly

“…According to the International classification of headache disorders, third edition (ICHD-3), TN is defined as a disorder characterized by recurrent, unilateral, brief, electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli [ 3 ]. The annual overall incidence of TN ranges from 12.6/100,000 to 27/100,000 people per year, with an increase in the incidence with advancing age [ 4 ]. The mechanism of TN is described as hyperexcitability of trigeminal root fibres near the entry zone into the pons because of mechanical compression (vascular or tumorous) or inflammatory demyelination (multiple sclerosis).…”

Is There a Magnetic Resonance Imaging-Discernible Cause for Trigeminal Neuralgia? A Structured Review

“…This is a clear indicator of microstructural changes in the nerve and, perhaps, demyelination, since FA is a measure of tissue microstructure. [4] The overall trend was that decreased FA values were found when comparing patients and controls as well as the affected and unaffected sides. This is consistent with the finding that nerve atrophy is associated with decreased FA values and that degradation of nerve structure indicates not only a compressive effect but also cellular changes.…”

“…[2, 4] Possible etiologies of the disease include neurovascular compression (NVC) [5], multiple sclerosis [6], tumors [7], arteriovenous malformations [8], and facial injury. [9] The most commonly accepted etiology in TN is thought to be related to NVC [1] as originally described by Dr. Janetta.…”

Neuropathic Pain in Multiple Sclerosis–Current Therapeutic Intervention and Future Treatment Perspectives

“…Trigeminal neuralgia (TN) is characterized by sudden, usually unilateral paroxysmal attacks of electric shock-like episodes of pain in specific facial or intraoral areas that affect one or more branches of the trigeminal nerve (49). The prevalence of trigeminal neuralgia in patients with MS ranges from 1 to 6.3%, corresponding roughly to 20 times the prevalence in the general population (8,41,50).…”