headache week case 2x - Ipswich-Year2-Med-PBL-Gp-2

Andy and Rick
 PC
• 56 y.o. male w. severe stabbing pains in the R. side of
• Appeared ~6mths ago. ↑ in frequency.
• Lasts only a few secs. Occurs several times a day
• Triggers – shaving, drinking, eating, windy days
• Recent wt. loss
• Dentist found no tooth-related issues
 Ex
• Neuro exam finds no abnormalities EXCEPT when the
face was tested for touch and pain (?) sensibility,
triggered an attack each time R. cheek was touched
DDX (wrong)
Dental pian (poor dentist?)
Temporal arteritis
Cluster headache
Maxillary sinusitis
TMJ dysfunction
Up-to-date DDx
• Short-lasting unilateral neuralgiform headache w.
conjunctival injection and tearing (SUNCT)
• Cluster tic syndrome
• Jabs and jolts syndrome
• ‘Other’ neuralgias (Postherpatic,
Provisional Dx
• Trigeminal Neuralgia
 Many potential causes of this
In short;
• there is insufficient evidence to support or refute the utility of MRI to identify
neurovascular compression in classic TN, or to indicate the most reliable MRI
• Neuroimaging with head CT or MRI is useful for identifying the small
proportion of patients who have a structural lesion (eg, tumor in the
cerebellopontine angle, demyelinating lesions including multiple sclerosis) as
the cause of secondary TN.
• In addition, high resolution MRI and magnetic resonance angiography (MRA)
may be useful for identifying vascular compression as the etiology of classic TN,
but the utility of these studies has not been established.
It is suggested to obtain brain MRI for patients in the following
groups to rule out a causative structural brain lesion:
• Patients with trigeminal sensory loss
• Patients with bilateral symptoms
• Young patients (under the age of 40)
carbamazepine controlled-release 100 mg orally, once or twice daily;
increase as tolerated and according to response every 7 days up to a
maximum of 600 mg twice daily.
After pain relief has been maintained for several weeks, the dose should be gradually
reduced to establish the minimum dose that will provide good pain control.
If carbamazepine is ineffective, options include referral to a neurosurgeon
or trial of other drugs alone or in combination with carbamazepine.
Murtagh suggests these as options for alternative drug therapy:
Possible procedures include:
 Decompression of the trigeminal nerve root (eg. Gel foam packing between the nerve and
blood vessels
 Thermocoagulation/radiofrequency neurolysis
 Surgical division of the peripheral branches
Trigeminal neuralgia (tic
douloureux) is a
condition of often
unknown cause that
typically occurs in
patients over the age of
50, affecting the second
and third divisions of the
trigeminal nerve and on
the same side of the
face.Brief paroxysms of
pain, often with
associated trigger
points, are a feature.
Site: sensory branches of the trigeminal nerve almost always unilateral (often right side)
Radiation: tends to commence in the mandibular division and spreads to the maxillary
division and (rarely) to the ophthalmic division
Quality: excruciating, searing jabs of pain like a burning knife or electric shock
Frequency: variable and no regular pattern
Duration: 1 - 2 minutes (up to 15 minutes)
Onset: spontaneous or trigger point stimulus
Offset: spontaneous
Precipitating factors: talking, chewing, touching trigger areas on face (e.g. washing,
shaving, eating), cold weather or wind, turning onto pillow
Aggravating factors: trigger points usually in the upper and lower lip, nasolabial fold or
upper eyelid
Relieving factors: nil
Associated features:
rarely occurs at night
spontaneous remissions for months or years
local pressure on the nerve root entry zone by tortuous pulsatile dilated small vessels (probably up to
multiple sclerosis
tumours of the posterior fossa
Signs: there are no signs, normal corneal reflex
Note: Precise diagnosis is essential.
Trigeminal neuralgia: typical
trigger points
Patient education, reassurance and empathic support is very important in
these patients.
Medical therapy:
carbamazepine (from onset of the attack to resolution)4 50 mg (elderly patient) or 100 mg
(o) bd initially, gradually increase the dose to avoid drowsiness every 4 days to 200 mg bd
(maintenance); testing serum levels is unnecessary; higher dosage may be necessary
• alternative drugs if carbamazepine not tolerated or ineffective (but question the diagnosis
if lack of response)
gabapentin 300 mg daily initially, then increase
phenytoin 300 - 500 mg daily
refer to a neurosurgeon if medication ineffective
possible procedures include:
 decompression of the trigeminal nerve root (e.g. gel foam packing between the nerve and
blood vessels)
 thermocoagulation/radiofrequency neurolysis
 surgical division of peripheral branches