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Okay, so the last headache syndrome that I'd
like to discuss is trigeminal neuralgia or [UNKNOWN].
Here is a picture trying to convey the
intense facial pain that the patient is experiencing.
And the underlying neural pathway.
Essentially the fifth cranial nerve.
And patients who have trigeminal neuralgia describe this intense,
electric shock like volley of, of just
horrible pain that radiates from the preauricular area.
Down into the cheek across towards the nose and its, its just so intense one of
the most horrific type of pain that can be that can occur for long periods of time.
In face there's some patients with trigeminal
neuralgia who are essentially never pain free.
the typical features are shown here, as I said these shock
like staccato, volleys of pain, interestingly
these pa, patients describe trigger sites.
Where an, if, if they touch a certain part of the
face or a cold breeze hits their face in a certain way,
or they're, they're eating food jaw movement of a certain type
will trigger volleys of pain The pain is almost always unilateral and
it affects the second and third branch of the cranial
nerve, almost never affecting the first or the ophthalmic branch.
And importantly, there's no other neurologic deficit.
A cranial nerve exam and the remainder of
the neorol, neurologic exam should be completely normal.
If not, it's quite possible that we're
talking about a different type of underlying disease.
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[SOUND] Here's the graphic of the time course of
trigeminal neuralgia, and as you can see the headache is
essentially is these jabs of pain which can occur multiple
times over the course of just a matter of minutes.
And if one looks more chronically this, this time scale could actually be.
Half a day or a day so many many, episodes of
these vollies of severe head pain.
The treatment of trigeminal neuralgia has, essentially two different options.
Medical or surgical.
Medical treatment relies primarily on anti-epileptic
drugs such as Carbamazepine, Lamotrigine or Valproate
and anti-depressant drugs such as Amitriptyline
or Nortriptyline can be useful as well.
For patients who don't respond to medical treatment there are a number of surgical
options which have varied success depending
on the approach and patient selection.
But one of the most important and commonly used, approaches
is decompression of a vessel over The fifth cranial nerve.
It appears that, at least in some patients a a blood vessel, typically an
artery, but sometimes a vein, may be
in direct contact with the fifth cranial nerve.
And perhaps it's the pulsation of that blood vessel that leads to injury
of the, of, of the trigeminal nerve and the result in trigeminal neuralgia.
In those cases, surgical exploration may reveal, as shown in this cartoon in
the upper right, the, the connection between
the, the blood vessel and the nerve.
And by placing a pad or a pledget that separates out the vessel this can lead to
a significant resolution of symptoms.
Another surgical option is selective ablation.
And this can be done either directly, surgically, or
indirectly using procedures such as gamma knife and thermal ablation.
So this brings us to the end
of our discussion of the primary headache disorders.
And in the next section we'll talk about the secondary headache disorders.
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Daniel Lowenstein, MDProfessor and Vice Chair, Department of Neurology
S. Andrew Josephson, MDAssociate Professor
Wade Smith, MDProfessor
