Upload
ms-trust
View
413
Download
0
Tags:
Embed Size (px)
DESCRIPTION
This presentation by Professor Joanna Zakrzewska, Head of facial pain unit at Eastman Dental Hospital, looks at trigeminal neuralgia in MS and how it's diagnosed and managed. It was presented at the MS Trust Annual Conference in November 2014.
Citation preview
Trigeminal neuralgia, facial pain in MS
Prof Joanna Zakrzewska
Head of facial pain unit
Eastman Dental Hospital
Aims and Objectives
Trigeminal neuralgia Diagnosis
Investigations
Medical management
Surgical management
Differential diagnosis
Epidemiology
Patho-
physiology
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
Incidence
per 100,000
PY
Hall et al
2006
Dieleman
2008
Koopman et
al 2009
Number 8,268
322 118
Incidence 26.8
28.9 12.6
Changing epidemiology of TN?
What are other causes of
unilateral episodic facial pain?
Drangsholt et al 2001
Dental causes of pain
Dental Pain – acute/ chronic
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
Temporomandibular Disorders
musculoskeletal
© Zakrzewska
TMD
© Zakrzewska
Education- explanation
© Zakrzewska
Education vs splint
Michelotti JADA 2012;143:47-53 © Zakrzewska
TMD management
Reassurance, education, relaxation, behaviour changes, intermittent
NSAID
Physiotherapy/ acupuncture, pain coping strategies, reinforce self
care, address psychological distress
Tricyclic antidepressants, cognitive behaviour
therapy, reinforce self care
© Zakrzewska
© Zakrzewska
Why is the right diagnosis important?
• Epidemiological studies
• Genetic studies
• Recruiting into clinical trials
• Appropriate managements and referrals
• Variants may involve different mechanisms
Who makes the diagnosis?
HCP making
diagnosis
TN
5287
ATN
189
OFP
857
General medical
practitioner % 36 36 18
Neurologist % 29 30 17
Dentist % 20 15 10
Other specialists % 15 19 55
Listen to your patient he is
telling you the diagnosis
The Story of Pain
curiosity to ask “tell me about yourself”
patience to wait for the answer Platt et al 2001
Stories
• patients tell stories to become who they are
• patient stories are addressed to someone
• the clinician must listen
• the quality of attention is important and
you " have to be caught up” – it is an act of
surrender
Misery by Rosa Sepple
What are the features of trigeminal neuralgia?
Character of TN pain
The character of trigeminal neuralgia is very
distinctive and pts will use words such electric
shock, lightening – implies speed as well as severity
© Zakrzewska
Duration
paroxysmal
pain of abrupt onset and termination
refractory intervals
no background pain
memorable first attack
© Zakrzewska
Temporal features
Refractory period
Classical TN TN – Type 2, concomitant pain
Periodicity of TN
Site and Radiation
Rare
© Zakrzewska
Provoking factors
R Conelly
Evoked vs spontaneous
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”.
How does TN affect quality of life ?
© Zakrzewska
© R. Sepple
Associated features Loneliness – isolation – how can
you go to social activities when
you cannot eat,
how can you be intimate when
you cannot bear your face to be
touched
How do you get across the
message that despite looking
normal you have one of the most
suicide pain
Depression is common
Fear of a returning attack is
always with the patients and
psychologist will tell us that this
drives further pain
Fear
©Eastman
Tolle et al Pain Practice 2006
The Patient’s Journey
Through Trigeminal Neuralgia Zakrzewska Padfield May 2014
Trigeminal Neuralgia
Limonadi et al 2006, Obermann et al 2007
What is the diagnosis of this
patient ?
Symptomatic TN
Trigeminal nerve
Tumour
© Zakrzewska
TG
MS plaque
vessel
nerve
Neurovascular compression
Aetiology / Pathophysiology
© Zakrzewska
Nerve Structure
Root entry zone, change in nerve
structure
Love and Coakham, Brain 2001: 124, 2347 – 2360
Management
Outcomes
Therapy % pain
relief
Decreased
intensity
frequency
Character of pain
Provoking factors
Side
effects
Beliefs
concerns
Objective
measures
© Zakrzewska
Health utilisation
Medical management
Systematic reviews guidelines
www.aan.com
Which have been evaluated in
Randomised controlled trials - RCTs?
baclofen carbamazepine
valproate lamotrigine epanutin
clonazepam
Which have been evaluated in RCTs?
gabapentin
pregabalin oxcarbazepine
sumatriptan
leviteracetam
Dextromethorphan
Topiramate
Botox
Carbamazepine
3 RCT studies (total 160 patients)
NNT 1.7 for >50% pain relief
Maximum 2.4 g / day
Usual dose 200-1,200 mg
NNH 2.6
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
Side effects to anticonvulsants
Acute management
Fosphenytoin infusion
Sumatriptan 3mg sc
24 patients in RCT
12/24 improved for mean 8 hours
Lidocaine
Injection
Intranasal
IV
Cheshire Fosphenytoin J Pain Sympt 2001
Kania Sumatriptan Head 2006
Han Lidocaine Clin Prac 2008, Kania Br J Aneasth 2006
Results of RCTs in TN
carbamazepine
oxcarbazepine
lamotrigine
baclofen
gabapentin + LA
pimozide =
tizanidine ?
tocainide
dextromethorphan ?
topiramate ?
AAN/ EFNS Guideline
New drug for TN
Novel Sodium Channel Blocker
CNV1014802 June 2014
• Treatment failure rate
33% CNV1014802 vs 65% placebo
• Decrease in pain severity
55% CNV1014802 vs 18% placebo
• Average reduction in number of paroxysms
60% CNV1014802 vs 12% placebo
Medications
There is a medicine
you can take
But it’s not the cure
It may make your
drowsy
It may make you sick
There are more pills
to take
And there’s no
miracle fix
Response to medication
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
Radiofrequency rhizotomy
Glycerol rhizotomy
Balloon compression
Microvascular decompression
Partial sensory rhizotomy
Posterior fossa
Zakrzewska Coakham Current Neurol 2012
Posterior fossa
Trigeminal nerve
compressed by
superior cerebellar
artery
© Prof H Coakham
Gamma knife
Radiation doses of 90- 70Gy
Non invasive ablative
procedure
Complete pain relief after surgery
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5years
% p
rob
ab
ilit
y
radiofrequency thermocoagulation percutaneous glycerol rhizotomy
microvascular decompression gamma knife
© Zakrzewska
data from 14 studies in 2785 patients
Complications
Mortality
0.2 - 0.5 % for MVD
© Zakrzewska
Complications
Peripheral ganglion lesions
© Zakrzewska
Complications
© Zakrzewska
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
Why are there few TN Drug Trials ? Diagnosis strictly clinical
Condition relatively rare
Medications may interfere with other drugs
Medications may take time to work
Spontaneous remission common
Side-effects may take time to appear
Pain very severe: justify using placebo
AAN/EFNS guidelines
Patient Information
© Zakrzewska
Support groups US , UK, Australia , Canada
Web sites : http://www.tna-support.org/
http://www.tna.org.uk/
© 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
Choice, Option, Decision
http://www.advancingqualityalliance.nhs.uk/SDM
References / further
reading
TN Review BMJ 2014
Guideline website
www.aan.com
Resources – e-learning
TMD & trigeminal neuralgia
http://cks.nice.org.uk/tmj-disorders
http://cks.nice.org.uk/trigeminal-neuralgia
Educational material
http://www.efic.org/
Year against orofacial pain
Summary
• Epidemiology provides
clues to aetiology
• Differential diagnosis
• Important diagnostic
features of TN
• Causes
• Investigations
• Management
• References
@ R.Sepple
Face to face Rosa Sepple
Thank you