Intravenous fosphenytoin as treatment for acute exacerbation of trigeminal neuralgia: A prospective systematic study of 15 patients

"Status trigeminal neuralgia": Analysis of 39 cases and proposal for diagnostic criteria

OBJECTIVE

The aim of this descriptive study was to propose diagnostic criteria for acute exacerbation of trigeminal neuralgia (TN) based on the analysis of retrospective cases.

BACKGROUND

TN is a rare and extremely painful condition whose evolution can be punctuated by major exacerbations, leading to significant functional impairment. Several denominations are used for these exacerbations: "acute exacerbation", "status of trigeminal neuralgia", and "status trigeminus". There is currently no clinical definition of this state. In this manuscript, we used the term "status trigeminal neuralgia" (STN).

METHODS

We conducted a retrospective study, in a tertiary care specialist headache center, in France. Patients were selected from January 2015 to October 2022, with the French translation of the keyword "STN", in the medical records (outpatients) or the codage for trigeminal neuralgia (inpatients). Additional cases of STN were prospectively recruited from October 2022 to February 2023. We analyzed the clinical and paraclinical data of these patients.

RESULTS

Thirty-nine patients presenting with STN were included. There was a preponderance of women (64%) with 24 cases of classic TN (62%) and 15 cases of secondary TN (38%). Concerning STN, 39 episodes were described. Pain was very severe in all patients. Cranial autonomic signs were present in 23% of cases. Pain extended beyond the usual territory in 44% of cases. A continuous pain background was present in 35% of cases. With regard to triggering factors, paroxysms of facial pain were triggered by eating (97% of patients), speaking (90%) or drinking (62% of patients). Repercussions on weight, hydration, or mood disorders were observed in 67%, 56% and 59% of the cases, respectively.

CONCLUSION

STN is a rare clinical presentation of TN. We proposed criteria and a new denomination for this condition.

Trigeminal neuralgia

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.

Safety and efficacy of carbamazepine in the treatment of trigeminal neuralgia: A metanalysis in biomedicine

Trigeminal neuralgia is a debilitating condition characterized by severe facial pain. Carbamazepine has been widely used as a first-line treatment option for trigeminal neuralgia, but there is a need to evaluate its safety and efficacy based on existing evidence. This meta-analysis aims to systematically assess the available literature and provide a comprehensive evaluation of the safety and efficacy of carbamazepine in the treatment of trigeminal neuralgia. A thorough search of electronic databases yielded a total of 15 relevant studies that met the inclusion criteria. The pooled analysis of these studies revealed that carbamazepine demonstrated significant efficacy in reducing pain intensity and frequency in patients with trigeminal neuralgia. Moreover, the drug was generally well-tolerated, with the most common adverse events being mild and transient. Subgroup analyses based on different dosages and treatment durations further supported the overall findings. However, caution should be exercised in patients with certain comorbidities or specific populations, as some rare but severe adverse events were reported. In conclusion, this meta-analysis provides strong evidence supporting the safety and efficacy of carbamazepine as a valuable therapeutic option for the management of trigeminal neuralgia. These results can guide clinicians in making informed decisions regarding the use of carbamazepine and contribute to optimizing treatment strategies for patients with trigeminal neuralgia. Further research is warranted to explore long-term safety and efficacy outcomes, as well as to compare carbamazepine with alternative treatment modalities.