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Ashina S, Robertson CE, Srikiatkhachorn A, Di Stefano G, Donnet A, Hodaie M, Obermann M, Romero-Reyes M, Park YS, Cruccu G, Bendtsen L. Trigeminal neuralgia. Nat Rev Dis Primers 2024; 10:39. [PMID: 38816415 DOI: 10.1038/s41572-024-00523-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/01/2024]
Abstract
Trigeminal neuralgia (TN) is a facial pain disorder characterized by intense and paroxysmal pain that profoundly affects quality of life and presents complex challenges in diagnosis and treatment. TN can be categorized as classical, secondary and idiopathic. Epidemiological studies show variable incidence rates and an increased prevalence in women and in the elderly, with familial cases suggesting genetic factors. The pathophysiology of TN is multifactorial and involves genetic predisposition, anatomical changes, and neurophysiological factors, leading to hyperexcitable neuronal states, central sensitization and widespread neural plasticity changes. Neurovascular compression of the trigeminal root, which undergoes major morphological changes, and focal demyelination of primary trigeminal afferents are key aetiological factors in TN. Structural and functional brain imaging studies in patients with TN demonstrated abnormalities in brain regions responsible for pain modulation and emotional processing of pain. Treatment of TN involves a multifaceted approach that considers patient-specific factors, including the type of TN, with initial pharmacotherapy followed by surgical options if necessary. First-line pharmacological treatments include carbamazepine and oxcarbazepine. Surgical interventions, including microvascular decompression and percutaneous neuroablative procedures, can be considered at an early stage if pharmacotherapy is not sufficient for pain control or has intolerable adverse effects or contraindications.
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Affiliation(s)
- Sait Ashina
- BIDMC Comprehensive Headache Center, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- BIDMC Comprehensive Headache Center, Department of Anaesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Giulia Di Stefano
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Anne Donnet
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, Centre Hospitalier Universitaire de Marseille, Hopital de la Timone, Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Mojgan Hodaie
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontairo, Canada
| | - Mark Obermann
- Department of Neurology, Hospital Weser-Egge, Hoexter, Germany
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marcela Romero-Reyes
- Department of Pain and Neural Sciences, Brotman Facial Pain Clinic, University of Maryland, School of Dentistry, Baltimore, MD, USA
| | - Young Seok Park
- Department of Medical Neuroscience, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
- Department of Neurosurgery, Gamma Knife Icon Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Giorgio Cruccu
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Lars Bendtsen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, University of Copenhagen, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Glostrup, Copenhagen, Denmark
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Nadeau SE, Lawhern RA. Management of chronic non-cancer pain: a framework. Pain Manag 2022; 12:751-777. [PMID: 35642546 DOI: 10.2217/pmt-2022-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA has doubled and a crisis has developed among the 15-20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain. Methods: Analytic review of the clinical literature. Results: Published science provides a solid framework for the management of chronic non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill with insights from clinical experience. Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances benefits and potential harms.
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Affiliation(s)
- Stephen E Nadeau
- Neurology Service & the Brain Rehabilitation Research Center, Malcom Randall VA Medical Center & the Department of Neurology, University of Florida College of Medicine, FL 32608-1197, USA
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Muñoz-Vendrell A, Teixidor S, Sala-Padró J, Campoy S, Huerta-Villanueva M. Intravenous lacosamide and phenytoin for the treatment of acute exacerbations of trigeminal neuralgia: A retrospective analysis of 144 cases. Cephalalgia 2022; 42:1031-1038. [PMID: 35469475 PMCID: PMC9442778 DOI: 10.1177/03331024221092435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Scant evidence is available on the use of intravenous pain treatment in acute
exacerbations of trigeminal neuralgia. The aim of this descriptive study was
to evaluate the effectiveness and security of intravenous lacosamide and
phenytoin in the treatment of acute trigeminal neuralgia pain. Methods We reviewed patients who attended the emergency department of a tertiary
hospital between 2012 and 2020 for exacerbations of trigeminal neuralgia
pain and were treated with either intravenous phenytoin or lacosamide for
the first time. Primary endpoints were pain relief and adverse effects
during the hospital stay. A comparative analysis between both treatment
groups was performed. Results We studied 144 episodes in 121 patients (median age 61 years, 66.1% women).
Trigeminal neuralgia etiology was secondary in 9.9%. Pain relief was
observed in 77.8% of 63 patients receiving lacosamide infusions, and adverse
effects in 1.6%. Pain relief was observed in 72.8% of 81 phenytoin infusions
and adverse effects in 12.3%, all mild. No difference was observed in pain
relief between groups, but the proportion of adverse effects was
significantly different (p = 0.023). Statistically significant differences
were also detected in readmissions within six months, time to readmission,
and pain relief status at first follow-up visit. Conclusion Intravenous lacosamide and phenytoin can be effective and safe treatments for
acute pain in trigeminal neuralgia. According to our series, lacosamide
might be better tolerated than phenytoin and lead to lower readmissions and
sustained pain relief.
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Affiliation(s)
- Albert Muñoz-Vendrell
- Neurology Department, Headache Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Silvia Teixidor
- Neurology Department, Headache Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jacint Sala-Padró
- Neurology Department, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergio Campoy
- Neurology Department, Headache Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.,Neurology Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | - Mariano Huerta-Villanueva
- Neurology Department, Headache Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.,Neurology Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
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