Trigeminal neuralgia: Diagnosis and treatment

Pathways to a diagnosis of trigeminal neuralgia: a qualitative study of patients' experiences

BACKGROUND

Trigeminal Neuralgia (TN) is a rare disorder which causes episodes of intense facial pain and has been described as the 'suicide disease'. Hence, prompt diagnosis and timely initiation of treatment is vital. However, delays to diagnosis and high rates of misdiagnosis are common, particularly within primary care. To date, most research has focused upon treatment options rather than improving diagnostic experiences. This study sought to explore patients' experiences of the events leading up to their TN diagnosis and their views about the care and support they received when they were diagnosed to provide recommendations for improving the TN diagnostic pathway.

METHODS

This was a qualitative, exploratory study using in-depth interviews. Interviews were conducted with (n = 25) UK-based people with TN recruited via online forums. Data were analysed thematically.

RESULTS

Following the onset of their TN pain, most participants described an arduous and uncertain journey to diagnosis, with many encountering significant delays, misdiagnoses and receiving inappropriate referrals and treatment. As a consequence, participants reported experiencing profound distress, anxiety, depression and, in extreme cases, suicidal ideation; some also described drug and alcohol misuse during this time. Most participants conveyed relief upon finally receiving a diagnosis. However, this was often by eclipsed by what they saw as poor and insensitive communication and inadequate information provisioning.

CONCLUSIONS

The present study highlights the importance of developing bespoke training for primary care and other professionals to facilitate timely recognition of TN symptomatology and ensure that they deliver a TN diagnosis in clear, sensitive and empathetic ways.

Internal neurolysis versus intraoperative glycerin rhizotomy for trigeminal neuralgia

OBJECTIVE

Internal neurolysis (IN) and intraoperative glycerin rhizotomy (ioGR) are emerging surgical options for patients with trigeminal neuralgia without neurovascular contact. The objective of this study was to compare the neurological outcomes of patients who underwent IN with those of patients who underwent ioGR.

METHODS

The authors retrospectively reviewed all patients who underwent IN or ioGR for trigeminal neuralgia at our institution. Patient demographic characteristics and immediate postoperative outcomes, as well as long-term neurological outcomes, were compared.

RESULTS

Of 1044 patients who underwent open surgical treatment for trigeminal neuralgia, 56 patients underwent IN and 91 underwent ioGR. Of these 147 patients, 37 had no evidence of intraoperative neurovascular conflict. All patients who underwent IN and 96.7% of patients who underwent ioGR had immediate postoperative pain relief. At last follow-up, patients who underwent IN had lower Barrow Neurological Institute (BNI) pain intensity scores (p = 0.05), better BNI facial numbness scores (p < 0.01), and a greater degree of pain improvement (p = 0.05) compared with those who underwent ioGR. Patients who underwent IN also had significantly lower rates of symptomatic pain recurrence (p < 0.01) at last follow-up over an average of 9.5 months.

CONCLUSIONS

IN appears to provide patients with a greater degree of pain relief, lower rates of facial numbness, and lower rates of pain recurrence compared with ioGR. Future prospective studies will better characterize long-term pain recurrence and outcomes.

Multivariate models to predict pain recurrence and sensitive complications after percutaneous balloon compression in trigeminal neuralgia

OBJECTIVE

Percutaneous balloon compression (PBC) is a popular treatment option for trigeminal neuralgia. However, the efficacy of PBC is widely considered to be associated with the occurrence of sensitive complications, although neither this correlation nor the underlying mechanisms have been established. The objectives of the present study were to identify factors predicting time to pain recurrence after PBC and identify factors predicting a severe sensitive complication.

METHODS

The authors conducted a retrospective study on patients who underwent PBC for the first time between 1985 and 2019 in two French hospitals. Data were retrieved from patients' medical records. Potential clinical and radiological predictors for time to pain recurrence and severe sensitive complication were evaluated using a Cox model and a logistic regression, respectively.

RESULTS

A total of 131 patients were included in the study, with a median follow-up of 3.0 years. Pain recurrence occurred in 77 patients, and the median time to pain recurrence was 2.0 years. In the multivariate analysis, six independent factors predicting pain recurrence were identified: 1) longer duration of presurgical symptoms; 2) localization of the pain along the mandibular branch of the trigeminal nerve (V3); 3) atypical pain; 4) diagnosis of multiple sclerosis; 5) use of a medical device not specifically adapted for trigeminal neuralgia surgery; and 6) duration of balloon compression > 60 seconds. Regarding the secondary objective, 26 patients presented a severe sensitive complication after PBC, which the authors defined as the development of a new sensitivity disorder of the cornea, deafferentation pain known as anesthesia dolorosa, and/or long-lasting hypoesthesia augmentation characterized by the new appearance or increase in size or intensity of an area of hypoesthesia in the face for at least 3 months. The only predictor associated with a severe sensitive complication in the multivariate analysis was compression duration > 60 seconds.

CONCLUSIONS

These results show that the risk of postoperative complications can be assessed at the patient level, the most important modifiable parameter being the time of compression by the balloon. Although this study shows the relevance of a personalized medicine approach, its clinical application remains to be validated.

Avellis syndrome with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central post-stroke pain: A case report and literature review

RATIONALE

Avellis syndrome is a rare bulbar syndrome. The main lesions may involve nucleus ambiguus and the lateral spinothalamic tract. The typical reported clinical manifestations are hoarseness, dysphagia, pain, and temperature disturbance of contralateral body. The manifestations, however, may vary. We aim to report new manifestations of Avellis syndrome in this report.

PATIENT CONCERNS

A 47-year-old Chinese peasant woman who felt sudden dizziness, nausea when she was doing the laundry was referred to our department from other hospital. She vomited the stomach contents once and complained numbness of the left trunk and limbs as well as coughing while drinking. The patient presented with palatopharyngeal paralysis, Horner syndrome, and diminished pain as well as temperature sensation in the contralateral face, trunk, and limbs. She also presented with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

DIAGNOSES

T2-weighted MRI images demonstrated a high-signal intensity lesion in the right medulla oblongata which indicated a banded infarction site. The patient was diagnosed with medulla oblongata infarction, Avellis syndrome, Horner syndrome, dysphagia, hemiparesthesia, ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

INTERVENTIONS

The patient was administrated aspirin to prevent the aggregation of platelet and rosuvastatin tablets to regulate lipids as well as to stabilize vascular plaque. She was injected with butylphthalide sodium chloride to improve nerve nutritional status and carbamazepine was prescribed to deal with prosopalgia and glossopharyngeal neuralgia. Gabapentin and pregabalin were administrated to deal with the central poststroke pain.

OUTCOMES

The symptoms of prosopalgia as well as glossopharyngeal neuralgia were gone, and dizziness, dysphagia, and Horner syndrome were significantly alleviated when she was discharged from the hospital while the interventions showed little effect on central poststroke pain.

LESSONS

We reported a case of Avellis syndrome who manifested as the typical reported manifestations. The patient, what's more, presented with ipsilateral trigeminal, glossopharyngeal neuralgia, and central poststroke pain which were described for the first time. It is of great significance for clinicians to recognize the typical as well as other manifestations which helps to make a clear diagnosis.

Pain Following Endoscopic Foreheadplasty Surgery in Women

BACKGROUND

Endoscopic foreheadplasty surgery (EFS) is a common procedure; however, little has been reported about the nature or treatment of postoperative headache pain and associated symptoms.

OBJECTIVES

The objective of this study was to describe the intensity, quality, location, and duration of headache pain in women following EFS. We also compared post-EFS symptoms with migraine, described medication use and efficacy, and measured emotional and functional outcomes.

METHODS

This descriptive study used an observational repeated-measures design. Forty-two women (mean [standard deviation] age, 59.0 [7.9] years) undergoing EFS were prospectively recruited from 12 private cosmetic practices in 3 California counties. Telephone interviews with the Acute Short-Form 12v2 and the Headache Pain Questionnaire were conducted on postoperative days (POD) 1, 3, 7, and 30.

RESULTS

On POD 1, 93% reported at least moderate pain and 64% severe pain. Severe pain was characterized as throbbing (71%), sharp (53%), dull (76%), exploding (41%), imploding (53%), continuous (53%), or intermittent (41%) on POD 1. Moderate pain was most frequent on POD 3 (21%) compared to POD 1 (19%), 7 (12%) and 30 (12%). Mild pain predominated on POD 3 (40%) and 7 (40%), with 20% remaining on POD 30. The majority (79%) of post-EFS symptoms included light sensitivity and nausea, and therefore met most International Classification of Headache Disorders criteria for migraine. Analgesic use provided inconsistent relief. Functional and emotional status did not return to baseline throughout the 30-day postoperative period.

CONCLUSIONS

Immediately following EFS, most women experience moderate to severe headache pain, despite use of medications. Pain persists in many patients for up to 1 month. Headache is associated with migraine symptoms, including light sensitivity and nausea.

LEVEL OF EVIDENCE: 4

Retrosigmoid approach for glycerin rhizotomy in the treatment of trigeminal neuralgia without overt arterial compression: updated case series

OBJECTIVE

Trigeminal neuralgia (TN) is a neuropathic pain disorder characterized by severe, lancinating facial pain that is commonly treated with neuropathic medication, percutaneous rhizotomy, and/or microvascular decompression (MVD). Patients who are not found to have distinct arterial compression during MVD present a management challenge. In 2013, the authors reported on a small case series of such patients in whom glycerin was injected intraoperatively into the cisternal segment of the trigeminal nerve. The objective of the authors' present study was to report their updated experience with this technique to further validate this novel approach.

METHODS

The authors performed a retrospective analysis of data obtained in patients in whom glycerin was directly injected into the inferior third of the cisternal portion of the trigeminal nerve. Seventy-four patients, including 14 patients from the authors' prior study, were identified, and demographic information, intraoperative findings, postoperative course, and complications were recorded. Fisher's exact test, unpaired t-tests, and Kaplan-Meier survival curves using Mantel log-rank test were used to compare the 74 patients with a cohort of 476 patients who received standard MVD by the same surgeon.

RESULTS

The 74 patients who underwent MVD and glycerin injection had an average follow-up of 19.1 ± 18.0 months, and the male/female ratio was 1:2.9. In 33 patients (44.6%), a previous intervention for TN had failed. On average, patients had an improvement in the Barrow Neurological Institute Pain Intensity score from 4.1 ± 0.4 before surgery to 2.1 ± 1.2 after surgery. Pain improvement after the surgery was documented in 95.9% of patients. Thirteen patients (17.6%) developed burning pain following surgery. Five patients developed complications (6.7%), including incisional infection, facial palsy, CSF leak, and hearing deficit, all of which were minor.

CONCLUSIONS

Intraoperative injection of glycerin into the trigeminal nerve is a generally safe and potentially effective treatment for TN when no distinct site of arterial compression is identified during surgery or when decompression of the nerve is deemed to be inadequate.

Introduction of pulsed radiofrequency cautery in infraorbital nerve block method for postoperative pain management of trauma-induced zygomaticomaxillary complex fracture reduction

Although various cases of neuralgia and its treatments have been reported, not enough evidence is present to recommend a single type of treatment as the most effective. The patient we have dealt with experienced significant interferences in his daily life due to chronic allodynia, but the symptom could not be resolved via previously reported treatments. We report a case of which a patient who presented infraorbital neuralgia after trauma was successfully treated by a novel treatment strategy. The patient was treated by applying infraorbital nerve block and pulsed radiofrequency cautery side by side. Through this report, we evaluate proper prevention and treatment strategies for patients who develop infraorbital neuralgia through similar etiologies.

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Tic versus TAC: differentiating the neuralgias (trigeminal neuralgia) from the cephalalgias (SUNCT and SUNA)

Trigeminal neuralgia, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) are classified as distinct disorders in the International Classification of Headache Disorders 3 beta (ICHD-3 beta). SUNCT and SUNA are primary headache disorders included among the trigeminal autonomic cephalalgias. Trigeminal neuralgia is classified under painful cranial neuropathies and other facial pains. The classification criteria of these conditions overlap significantly which could lead to misdiagnosis. The reported overlap among these conditions has called into question whether they should be considered distinct entities or rather a continuum of the same disorder. This review explores the known overlap and how other features not included in the ICHD-3 beta criteria may better differentiate the "Tics" (trigeminal neuralgia) from the "TACs" (SUNCT and SUNA).

Neuronavigation-assisted percutaneous balloon compression for the treatment of trigeminal neuralgia: The technique and short-term clinical results

BACKGROUND

Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia. However, this technique has a steep learning curve and significant complications were reported that were related to foramen ovale puncturing. The aim of this study was to evaluate the clinical results of a small patient group who underwent neuronavigation-assisted PBC.

METHODS

An intraoperative computed tomography (CT) device (CereTom, Neurologica, Danvers, MA/USA) was used to obtain CT scans with 2-mm slice thicknesses. The data were transferred to a neuronavigation system planning station (BrainLab, Feldkirchen, Germany). A soft touch registration system was used for image registration. With the image guidance, a trajectory was defined and the foramen ovale was cannulated using neuronavigation and Hartel's landmarks.

RESULTS

Sixteen procedures were performed on 13 patients (4 female and 9 male) without complications. The total length of the procedure was not more than 57 min in all instances.

CONCLUSIONS

We believe that image-guided neuronavigation is useful for neurosurgeons who are at the beginning of their PBC learning curve. It may also be an alternative for particular patients with significant anatomic variations that result in an unsuccessful foramen ovale puncture.

The Effect of Low-level Laser Therapy on Trigeminal Neuralgia: A Review of Literature

The effect of low intensity laser radiation in the treatment of acute and chronic pain is now established in many studies. Tri-geminal neuralgia is a pain passes through nerve's branches and its trigger is located in skin or mucosa that could lead to pain with a trigger stimulus. The pain involved branches of trigeminal nerve that sometimes has patients to seek the treatment for several years. Nowadays different treatments are used for relief of pain that most of them cause tolerance and various side effects. This paper reviews and summarizes scientific papers available in English literature publishedin PubMed, Scopus, Science Direct, Inter science, and Iran Medex from 1986 until July 2011 about the effect of these types of lasers on trigeminal neuralgia which is one of the most painful afflictions known. In different studies, the effect of laser therapy has been compared with placebo irradiation or medicinal and surgical treatment modalities. Low-level laser therapy (LLLT) is a treatment strategy which uses a single wavelength light source. Laser radiation and monochromatic light may alter cell and tissue function. However, in most studies laser therapy was associated with significant reduction in the intensity and frequency of pain compared with other treatment strategies, a few studies revealed that between laser and placebo group there was not any significant difference according to the analgesic effect. Low-level laser therapy could be considered in treatment of trigeminal neuralgia without any side effects.

Glossopharyngeal neuralgia secondary to vascular compression in a patient with multiple sclerosis: a case report

Introduction

Glossopharyngeal neuralgia is an uncommon, painful syndrome, characterized by paroxysms of pain in the sensory distribution of the 9th cranial nerve. Idiopathic glossopharyngeal neuralgia may be due to compression of the glossopharyngeal nerve by adjacent vessels, while secondary glossopharyngeal neuralgia is associated with identifiable lesions affecting the glossopharyngeal nerve at different levels of its neuroanatomic pathway. Glossopharyngeal neuralgia is rare in the general population, but is more common in patients with multiple sclerosis.

Case presentation

A 56-year-old Caucasian woman with multiple sclerosis and migraine presented to our facility with intermittent lancinating pain to the right of her throat, tongue, and the floor of her mouth that had been occurring for the past year. The pain was intense, sharp, and stabbing, which lasted two to six seconds with radiation to the right ear. Initially, the attacks were infrequent, however, they had become more intense and frequent over time. Our patient reported weight loss, headache, painful swallowing, and the inability to maintain sleep due to painful attacks. A neurological examination revealed a right-handed woman with trigger points in the back of the tongue and throat on the right side. She also had dysphagia, hoarseness, and pain in the distribution of the right glossopharyngeal nerve. Mild right hemiparesis, hyperreflexia, dysmetria, and an ataxic gait were present. A magnetic resonance imaging scan of the brain was consistent with multiple sclerosis and magnetic resonance angiography demonstrated a loop of the posterior inferior cerebellar artery compressing the right glossopharyngeal nerve. She responded satisfactorily to carbamazepine. Microvascular decompression and Gamma Knife® radiosurgery were discussed in case of failure of the medical treatment; however, she declined these options.

Conclusions

Glossopharyngeal neuralgia in multiple sclerosis may occur due to vascular compressive lesions and it should not be solely attributed to the underlying demyelinating process. Vascular compression of the glossopharyngeal nerve could independently cause glossopharyngeal neuralgia in patients with multiple sclerosis, and vascular imaging to exclude such a diagnosis is recommended.

Trigeminal neuralgia: frequency of occurrence in different nerve branches

Background:

Trigeminal neuralgia (TN) is neuropathic pain which can involve any part or side of the face.

Objectives:

The objectives of this study were to find the most common branch of trigeminal nerve affected and the most common side involved.

Patients and Methods:

This Cross sectional study was carried out on 100 patients of trigeminal neuralgia in one year time. The diagnosis was based on a detailed history, clinical examination and control of pain by carbamazepine being taken supplemented by radiographic investigations. The collected data was analysed by SPSS 16.

Results:

The age of the patients varied from 40 to 80 years with a mean age 54 years at the time of presentation. The males to females ratio was 1:2. The right side of the face was found to be involved in seventy patients (64 %) and left side in (36 %). No case presented with bilateral involvement. The Mandibular division was most commonly involved in this study (n = 55; 55%) and least was ophthalmic divisions (n = 6; 6%).

Conclusions:

This study demonstrated numerous clinical similarities of trigeminal neuralgia afflicting different populations. Right side was more involved along with mandibular division the most commonly affected. However studies needs to be done to know the exact reasons of involvement of the affected side and branches.

Pharmacological versus microvascular decompression approaches for the treatment of trigeminal neuralgia: clinical outcomes and direct costs

In idiopathic trigeminal neuralgia (TN) the neuroimaging evaluation is usually normal, but in some cases a vascular compression of trigeminal nerve root is present. Although the latter condition may be referred to surgery, drug therapy is usually the first approach to control pain. This study compared the clinical outcome and direct costs of (1) a traditional treatment (carbamazepine [CBZ] in monotherapy [CBZ protocol]), (2) the association of gabapentin (GBP) and analgesic block of trigger-points with ropivacaine (ROP) (GBP+ROP protocol), and (3) a common TN surgery, microvascular decompression of the trigeminal nerve (MVD protocol). Sixty-two TN patients were randomly treated during 4 weeks (CBZ [n = 23] and GBP+ROP [n = 17] protocols) from cases of idiopathic TN, or selected for MVD surgery (n = 22) due to intractable pain. Direct medical cost estimates were determined by the price of drugs in 2008 and the hospital costs. Pain was evaluated using the Numerical Rating Scale (NRS) and number of pain crises; the Hospital Anxiety and Depression Scale, Sickness Impact Profile, and satisfaction with treatment and hospital team were evaluated. Assessments were performed at day 0 and 6 months after the beginning of treatment. All protocols showed a clinical improvement of pain control at month 6. The GBP+ROP protocol was the least expensive treatment, whereas surgery was the most expensive. With time, however, GBP+ROP tended to be the most and MVD the least expensive. No sequelae resulted in any patient after drug therapies, while after MDV surgery several patients showed important side effects. Data reinforce that, (1) TN patients should be carefully evaluated before choosing therapy for pain control, (2) different pharmacological approaches are available to initiate pain control at low costs, and (3) criteria for surgical interventions should be clearly defined due to important side effects, with the initial higher costs being strongly reduced with time.

Trigeminal neuralgia: for one nerve a multitude of treatments

Trigeminal neuralgia (TN) is reputed to be one of the most painful conditions in human experience. Thus, many treatments, both medical and surgical, have been developed for this relapsing and remitting, paroxysmal stabbing or electrical, facial pain syndrome. The likely etiology in many cases is vascular compression of the trigeminal nerve root entry zone, leading to focal demyelination and aberrant neural discharges. MRI may disclose neurovascular contact, although not with sufficient sensitivity or specificity to substitute for careful clinical diagnosis. In treating TN, antiepileptic drugs are superior to traditional analgesics. Carbamazepine is the first choice drug. Additional drugs for which there is evidence of efficacy include oxcarbazepine, baclofen, gabapentin, lamotrigine and phenytoin. Many patients eventually experience tachyphylaxis or may not tolerate effective doses. Surgical options include: microvascular decompression; balloon compression; radiofrequency thermocoagulation or glycerol rhizotomies; and subcutaneous alcohol branch blockade. Stereotactic gamma knife radiosurgery is a further option. Motor cortex stimulation and transcranial magnetic stimulation, although having shown initial promise for trigeminal neuropathic pain, seem to be ineffective for classical TN. The choice of drug, whether or when to operate, and which procedure to choose should be individualized to the particular needs and conditions of the patient.

Trigeminal neuralgia

The paroxysmal facial pain of trigeminal neuralgia is notoriously severe. Recent advances in medical science are achieving significant strides toward alleviating this incapacitating condition. High-resolution neuroimaging techniques are rendering detailed views of underlying neurovascular relationships. Newer antiepileptic medications and novel therapies are proving helpful in treating pain resistant to carbamazepine. Further developments also in targeted neurosurgical and radiosurgical techniques are providing pain relief within increasingly wider margins of safety. Much has been accomplished, yet much remains to be done.

Patient burden of trigeminal neuralgia: results from a cross-sectional survey of health state impairment and treatment patterns in six European countries

Trigeminal neuralgia (TN) is an uncommon neuropathic condition associated with excruciating facial pain. It is important to determine the effect of TN pain on patient functioning and to characterize relevant pharmacologic treatment patterns and health resource utilization in general practice. Eighty-two patients with TN were identified in a general practice setting during an observational survey of broad neuropathic pain syndromes in six European countries. Patients answered a questionnaire that included pain severity and interference items from the modified Short Form Brief Pain Inventory (mBPI-SF), the EuroQol Survey of functioning and well-being (EQ-5D), and questions related to current treatment, health status, and resource utilization. Physicians provided information on medications prescribed for TN pain and pain-related comorbidities (anxiety, depression, and sleep disturbance). The mean patient age was 62.7 +/- 15.8 years, 46% were > or =65 years, and 66% of patients had TN >1 year of duration. The mean Pain Severity Index was 4.2 (range 0-10), reflecting moderate pain despite 94% of patients taking prescription medications for their TN pain. Prescription medications included carbamazepine (mean daily dose 534.1 +/- 269.8 mg), the recommended first-line pharmacologic therapy for TN. Pain severity was significantly associated with reduced EQ-5D health state valuation (P < 0.001) and greater pain interference (mBPI-SF) (P < 0.001). These findings demonstrate that TN pain presents a substantial patient burden expressed as interference with daily functioning and reduced health status associated with pain severity. This burden may result from both suboptimal management strategies and the frequent resistance of this neuropathic condition to treatment, and suggests a need for more effective pain management strategies.

Trigeminal neuropathic pain alters responses in CNS circuits to mechanical (brush) and thermal (cold and heat) stimuli

Functional magnetic resonance imaging was used to study patients with chronic neuropathic pain involving the maxillary region (V2) of the trigeminal nerve in patients with spontaneous pain and evoked pain to brush (allodynia). Patients underwent two functional scans (2-3 months apart) with mechanical and thermal stimuli applied to the affected region of V2 and to the mirror site in the unaffected contralateral V2 region, as well as bilaterally to the mandibular (V3) division. Patients were stimulated with brush, noxious cold, and noxious heat. Significant changes were observed in regions within and outside the primary trigeminal sensory pathway. Stimulation to the affected (neuropathic) side resulted in predominantly frontal region and basal ganglia activation compared with the control side. The differences were consistent with the allodynia to brush and cold. A region of interest-based analysis of the trigeminal sensory pathway revealed patterns of activation that differentiated between the affected and unaffected sides and that were particular to each stimulus. Activation in the spinal trigeminal nucleus was constant in location for all pain stimuli. Activation in other brainstem nuclei also showed differences in the blood oxygenation level-dependent signal for the affected versus the unaffected side. Thus, sensory processing in patients with trigeminal neuropathic pain is associated with distinct activation patterns consistent with sensitization within and outside of the primary sensory pathway.

Trigeminal Neuralgia in Wind Musicians

The author reports 3 patients with trigeminal neuralgia whose pain was triggered by musical performance. Use of the muscles of embouchure activated the trigger zone when playing the clarinet, saxophone, flute, piccolo, trombone, or whistling. In each case, the location of the trigger zone was perioral, regardless of which division of the trigeminal nerve emanated pain. Trigeminal neuralgia is a particularly disabling affliction when it occurs in wind musicians.

Glossopharyngeal neuralgia

Glossopharyngeal neuralgia is a distinctive syndrome, named by Wilfred Harris. Investigation must exclude multiple sclerosis, and local compression, especially by tumours which require treatment. Dandy deserves credit for first indicating vascular compression of cranial nerve roots as a cause of cranial neuralgias, and Jannetta for establishing neurovascular decompression. Vascular compression is a common and treatable cause but does not account for all previously designated idiopathic cases.

Recent advances in elucidating pain mechanisms

PURPOSE OF REVIEW

The purpose of this review is to highlight the important recent advances in this fast developing field of pain mechanisms. It is now recognized that acute tissue and neural injuries can result in nociceptor sensitization (primary hyperalgesia) and spinal cord hyperexcitability or central sensitization that results in secondary hyperalgesia and allodynia.

RECENT FINDINGS

New findings regarding peripheral and central sensitization are presented in this review. Newer ideas on pain modulation, pain states and pain syndromes, mechanisms of chronic pain, newer opioid and non opioid medications including newer N-methyl-D-asparate antagonists, cyclooxygenase-2 inhibitors and membrane stabilizing analgesics as well as pain control at the genetic level are discussed.

SUMMARY

The research of the last decade has focused on the biochemical and structural plasticity of the nervous system following tissue and nerve injury. The mechanisms involved in the transition from acute to chronic pain are complex with the involvement of interacting receptor systems and intracellular ion flux, second messenger systems, new synaptic connections and apoptosis.