Trigeminal neuralgia in MS patients

Prof Joanna Zakrzewska

Facial pain unit, Eastman Dental Hospital

MS Trust Annual Conference 2015

Aims and Objectives

Trigeminal neuralgia

2. Diagnosis

Investigations

4. Medical management

Surgical management

3. Impact

1. Epidemiology

Types of facial

pain

5. Research questions

Epidemiology TN

Incidence : 4.5 / 100,000

Prevalence : 0.001% - 0.3%

Peak incidence : 50-60 years

Multiple sclerosis (2- 4 % of TN patients)

Hypertension

Stroke

Zakrzewska JM, Hamlyn PJ. In Epidemiology of

Pain. IASP, 1999

Mueller D et al Cephalagia 2011

Pan et al Cephalagia 2011

Drangsholt et al 2001

What are other causes of unilateral episodic facial pain?

Chronic continuous pain

Unilateral continuous orofacial pain

Yes No

Yes No

• Post herpetic

neuralgia

• Post traumatic

trigeminal pain

• Anesthesia

dolorosa

• Persistent

dentoalveolar

pain

• Referred pain

• Temporomandibular

disorders**

• Persistent orofacial

muscle pain **

Unilateral episodic orofacial pain

Yes No

• Trigeminal

neuralgia

classical (type 1)

• Trigeminal

neuralgia

symptomatic

• Trigeminal

neuralgia +

concomitant pain

( type 2)

• Glossopharyngeal

neuralgia

• Tension type

headache

• Medication

overuse

headache

• Post stroke pain

• Giant cell arteritis *

Cancer pain

Burning mouth

syndrome

Chronic migraine • Trigeminal autonomic

cephalagias

• Episodic migraine *

Persistent idiopathic facial

pain

Zakrzewska BJA 2013

Trigeminal Neuralgia –IASP

a sudden, usually

unilateral, severe,

brief, stabbing,

recurrent pain in

the distribution of

one or more

branches of the

fifth cranial nerve.

Misery by Rosa Sepple

Character of TN pain

Sharp

Electric shock like

Stabbing

Fearful

Unbearable

© Zakrzewska

Duration

paroxysmal

pain of abrupt onset and termination

refractory intervals

no background pain

memorable first attack

© Zakrzewska

Temporal features

Classical TN TN – Type 2, concomitant pain

Periodicity of TN

Site and Radiation

Rare

© Zakrzewska

Provoking factors

Light touch provoked#

Eating/brushing teeth

Washing /shaving

Cold wind

Evoked vs spontaneous

60 sec

45 sec

30 sec

15 sec

Attack of TN

@ Prof Sharav

Associated features

Unable to maintain good oral hygiene

Loneliness

Depression

Effects of TN

I try so hard to laugh

and joke, so I do not

cry. I am sick of

crying, it is time to

laugh and try to find

some enjoyment in

my life again

People tell me that I

look good and I must

be feeling pretty

good. They tell me

many people are in

worse pain than I am

Effect of TN

I feel that I am a

burden to my family,

very, very frustrated

at lack of ability to

do things and go

places.

Constantly

cancelling

attendance at events

... very poor quality

of life now –

maddening

My whole life was falling

apart. Everything was

falling apart in our

house, my job and there

was nothing I could do

about the pain.

Fear

©Eastman

Tolle et al Pain Practice 2006

The Patient’s Journey

Through Trigeminal Neuralgia Zakrzewska Padfield May 2014

Trigeminal Neuralgia

Same in MS patients?

Maarjberg et al 2014; Limonadi et al 2006, Obermann et al 2007

Symptomatic TN

Trigeminal nerve

Tumour

© Zakrzewska

TG

MS plaque

vessel

nerve

Neurovascular compression

Systematic reviews guidelines

www.aan.com

Zakrzewska JM, Linskey M 2014

Drugs used in TN

baclofen carbamazepine

valproate lamotrigine epanutin

clonazepam

Drugs used in TN

gabapentin

pregabalin oxcarbazepine

sumatriptan

leviteracetam

Dextromethorphan

Topiramate

Botox

Carbamazepine

3 RCT studies (total 280 patients)

Number Needed to Treat

2 for >50% pain relief

Maximum 2.4 g / day

Usual dose 200-1,200 mg

Number needed to harm 4

Multiple drug interactions

Carbamazepine adverse events

osteoporosis

© Zakrzewska

Oxcarbazepine

Starting 300 mg bd

Dose range 600-1,200 mg /day

Maximum 2,400 mg/day

Hyponatraemia higher doses

Few drug interactions

Adverse effects of AEDs using AEP

161 patients

Women more sensitive

to carbamazepine and oxcarbazepine

Besi et al J Headache Pain 2015

Pain diaries

Drug dosages

Change of pain

AAN/ EFNS Guideline

Do they apply to MS patients?

Insufficient evidence to say

when surgery should be offered

Patients should be given details of all surgical procedures

Systematic review surgery

3 studies

2 radiofrequency

thermocoagulation

comparing techniques

1 stereotactic surgery

comparing dosages

Cochrane Database of Systematic Reviews 2011, Issue 9

Grading

Gasserian Ganglion procedures

Ablative/ destructive

Radiofrequency rhizotomy

Glycerol rhizotomy

Balloon compression

Stereotactic radiosurgery

Gamma knife, Cyberknife

Radiation doses of 90- 70Gy

Non invasive

Destructive procedure

Microvascular decompression

Non destructive

Posterior fossa

Zakrzewska Coakham Current Neurol 2012

AAN/EFNS guidelines

Does this apply to MS patients?

How 302 patients with MS and TN

compare with 7982 TN only patients ?

Same age and demographics

More constant, bilateral pain

Use wider range of drugs Undergo more ablative surgery

Support groups US , UK, Australia , Canada

Web sites : http://www.tna-support.org/

http://www.tna.org.uk/

© Zakrzewska

Patient Information

© Zakrzewska

Microvascular

decompression

MS

Drug

therapy

Neurovascular compression

Drug therapy

Tumours etc

Idiopathic TN

MRI

Blood tests Symptomatic TN

Ablative procedures Gasserian

ganglion

Gamma knife

Trigeminal neuralgia Primary care

Carbamazepine

Initial good control but now failing

Refer pain clinic

Neurology headache

Neurosurgery Poor

quality of

life

Carbamazepine

Oxcarbazepine

Lamotrigine

Baclofen

Pregablin

Gabapetin

Joint neurosurgery

clinic Psychology

© Zakrzewska

TN Review BMJ 2014

Zakrzewska JM , Linskey ME 2015 BMJ Clinical Evidence

Podcast on Trigeminal neuralgia available at

http://www.bmj.com/content/350/bmj.h1238

Guideline website

www.aan.com

Resources – e-learning

Trigeminal neuralgia

http://cks.nice.org.uk/trigeminal-neuralgia

Educational material

http://www.efic.org/

Year against orofacial pain 2013-4

Rosa Sepple

http://www.rosasepple.com/index.htm

The Mall

Solo exhibition 2015

Unresolved questions

• How many patients with MS have facial

pain?

• How many patients with MS have TN and

its variants?

• How do they respond to drug therapy?

• Should MS patients have destructive

procedures?

• Do MS patients need more support?

Interested in helping?

J.Zakrzewska @ucl.ac.uk

TNA Jillie Abbott admin@tna.org.uk