prof joanna zakrzewska - trigeminal neuralgia in ms patients
TRANSCRIPT
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Trigeminal neuralgia in MS patients
Prof Joanna Zakrzewska
Facial pain unit, Eastman Dental Hospital
MS Trust Annual Conference 2015
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Aims and Objectives
Trigeminal neuralgia
2. Diagnosis
Investigations
4. Medical management
Surgical management
3. Impact
1. Epidemiology
Types of facial
pain
5. Research questions
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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
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Drangsholt et al 2001
What are other causes of unilateral episodic facial pain?
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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
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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
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Character of TN pain
Sharp
Electric shock like
Stabbing
Fearful
Unbearable
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© Zakrzewska
Duration
paroxysmal
pain of abrupt onset and termination
refractory intervals
no background pain
memorable first attack
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© Zakrzewska
Temporal features
Classical TN TN – Type 2, concomitant pain
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Periodicity of TN
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Site and Radiation
Rare
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© Zakrzewska
Provoking factors
Light touch provoked#
Eating/brushing teeth
Washing /shaving
Cold wind
Evoked vs spontaneous
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60 sec
45 sec
30 sec
15 sec
Attack of TN
@ Prof Sharav
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Associated features
Unable to maintain good oral hygiene
Loneliness
Depression
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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
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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.
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Fear
©Eastman
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Tolle et al Pain Practice 2006
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The Patient’s Journey
Through Trigeminal Neuralgia Zakrzewska Padfield May 2014
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Trigeminal Neuralgia
Same in MS patients?
Maarjberg et al 2014; Limonadi et al 2006, Obermann et al 2007
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Symptomatic TN
Trigeminal nerve
Tumour
© Zakrzewska
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TG
MS plaque
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vessel
nerve
Neurovascular compression
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Systematic reviews guidelines
www.aan.com
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Zakrzewska JM, Linskey M 2014
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Drugs used in TN
baclofen carbamazepine
valproate lamotrigine epanutin
clonazepam
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Drugs used in TN
gabapentin
pregabalin oxcarbazepine
sumatriptan
leviteracetam
Dextromethorphan
Topiramate
Botox
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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
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Carbamazepine adverse events
osteoporosis
© Zakrzewska
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Oxcarbazepine
Starting 300 mg bd
Dose range 600-1,200 mg /day
Maximum 2,400 mg/day
Hyponatraemia higher doses
Few drug interactions
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Adverse effects of AEDs using AEP
161 patients
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Women more sensitive
to carbamazepine and oxcarbazepine
Besi et al J Headache Pain 2015
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Pain diaries
Drug dosages
Change of pain
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AAN/ EFNS Guideline
Do they apply to MS patients?
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Insufficient evidence to say
when surgery should be offered
Patients should be given details of all surgical procedures
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Systematic review surgery
3 studies
2 radiofrequency
thermocoagulation
comparing techniques
1 stereotactic surgery
comparing dosages
Cochrane Database of Systematic Reviews 2011, Issue 9
Grading
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Gasserian Ganglion procedures
Ablative/ destructive
Radiofrequency rhizotomy
Glycerol rhizotomy
Balloon compression
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Stereotactic radiosurgery
Gamma knife, Cyberknife
Radiation doses of 90- 70Gy
Non invasive
Destructive procedure
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Microvascular decompression
Non destructive
Posterior fossa
Zakrzewska Coakham Current Neurol 2012
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AAN/EFNS guidelines
Does this apply to MS patients?
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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
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Support groups US , UK, Australia , Canada
Web sites : http://www.tna-support.org/
http://www.tna.org.uk/
© Zakrzewska
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Patient Information
© Zakrzewska
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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
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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
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Guideline website
www.aan.com
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Resources – e-learning
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Trigeminal neuralgia
http://cks.nice.org.uk/trigeminal-neuralgia
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Educational material
http://www.efic.org/
Year against orofacial pain 2013-4
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Rosa Sepple
http://www.rosasepple.com/index.htm
The Mall
Solo exhibition 2015
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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 [email protected]