Trigeminus neuralgie versus cluster hoofdpijn

Trigeminus neuralgie
versus cluster hoofdpijn
Koen Paemeleire, Neurologie UZ Gent
Erwin Crombez, Pijnkliniek/MPC UZ Gent
16 september 2014
- A mean diagnostic delay of 44 months was reported
- Most common misdiagnoses were migraine (45%), sinusitis (23%), tooth/jaw problems
(23%), tension-type headache (16%) and trigeminal neuralgia (16%)
- A significant percentage of patients had never received access to
injectable sumatriptan (26%) or oxygen (31%)
- Despite the CH diagnosis… propranolol (12%), amitriptyline (9%), carbamazepine (12%)
- 31% of patients had undergone invasive therapy prior to CH diagnosis, including
dental procedures (21%) and sinus surgery (10%)
http://www.ihs-classification.org/_downloads/mixed/International-HeadacheClassification-III-ICHD-III-2013-Beta.pdf
Cluster headache 3.1
Trigeminal neuralgia 13.1
Trigeminal neuralgia
- Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should
be offered as first-line treatment for pain control
Trigeminal neuralgia
“Other drugs for which there is some evidence
include lamotrigine and baclofen”
“Pregabalin has potential”
“TN refractory to medical therapy: early surgical
therapy may be considered”
Eur J Neurol 2008;15:1013-1028
Cohrane Database Syst Rev 2011;2:CD006044
Cephalalgia 2008;28:174-181
Br J Anaesth 2013;111(1):95-104
- Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should
be offered as first-line treatment for pain control
- For patients with TN refractory to medical therapy early surgical therapy may be
considered. Gasserian ganglion percutaneous techniques, gamma knife and
microvascular decompression may be considered.
- Microvascular decompression may be considered over other surgical techniques to
provide the longest duration of pain freedom
- The role of surgery versus pharmacotherapy in the management of TN in
patients with multiple sclerosis remains uncertain
Complications of surgery
PGL: Percutaneous Gasserian Lesions (includes radiofrequency thermocoagulation, glycerol
rhizotomy, balloon compression)
MVD: Microvascular Decompression
GKS: Gamma Knife Surgery.
percutane interventies voor TN (1)
• microvascular decompression is considered the gold standard
• percutaneous techniques remain an effective option for some patients
• most common procedures: balloon compression (BC), glycerol rhizotomy (GR), and
radiofrequency thermocoagulation (RF)
• no randomized clinical trial exists comparing the efficacy and long-term outcomes
of these procedures
• atypical symptoms are negative predictor of long-term efficacy across all
treatments
• patients with MS have higher recurrence rates and require more treatments
percutane interventies voor TN (2)
• BC
• selectively injures larger pain fibers while sparing small fibers (useful in Va
pain: sparing of the corneal reflex)
• does not require an awake, cooperative patient
• more often trigeminal depressor response (hypotension, bradycardia)
• pain relief in up to 91% at 6 months and 66% at 3 years
• patients unable to tolerate general anesthesia or those with significant cardiac
histories are generally poor candidates
• dysesthesia in 10% to 20%, severe numbness in 20%
• masseter weakness typically resolves within 12 months
percutane interventies voor TN (3)
• RF
• T° monitoring, short-acting anesthetic agents and electric stimulation with
awake-patient feedback is needed to minimize side effects
• somatotopic nerve mapping and selective division lesioning
• pain relief in up to 97% initially and 58% at 5 years
• multiple treatments improve outcomes but carry significant morbidity risk
• masticatory weakness up to 29%, dysesthesia average 3.7%, corneal
numbness average 9.6%
percutane interventies voor TN (4)
• GR
•
•
•
•
does not require an awake patient
trigeminal depressor response in up to 20%
contrast cisternogram and injection of glycerol in sitting position
after injection patient remains sitting for 2 h to prevent leakage into the
posterior fossa
• pain relief in up to 90% at 6 months and 54% at 3 years
• pain relief correlates with degree of numbness
• dysesthesias in 8.3%, corneal numbness in 8.1%, masseter weakness in 3.1%
Cluster headache
Cluster hoofdpijn
verapamil
Neurology 2007 ;69(7):668-75
≥ 12 L/minuut
Gedurende ≥ 15 min
Non rebreathing mask
JAMA 2009;302(22):2451-2457
interventies voor (C)CH (1)
• infiltratie GON
• Alfridi et al (Pain 2006): 19 pt, lidocaine + steroid, ECH vs CCH
• 53% (10/19) complete pain free for mean 17 days
• 15% (3/19) > 30% pain reduction
• Ambrosini et al (Pain 2005): 23 ECH / 7 CCH, lidocaine + steroid vs
lidocaine
• 84% (11/13) at least 4 weeks complete pain relief
• 38% (5/13) > 4 months
• Leroux et al (Lancet Neurology 2011): 28 ECH / 15 CCH, 3 inject, steroid
vs placebo
• steroid: mean 10,6 attacks first 15 days vs placebo: mean 30,3
attacks
• SPG block
• Devoghel et al (Acta Anesthesiol. Belgica 1981)
• 85% (102/120) temporary pain relief
interventies voor (C)CH (2)
• SPG RFA
• Sanders M et al. (J Neurosurg. 1997), 56 ECH / 10 CCH, 12-70 mth
follow-up
• ECH: 60,7% complete relief, 25% partial (= from 3.3 to 2.3 a/d)
• CCH: 30% complete relief, 30% partial relief
• (4 pt: 1 RF, 3 pt: 2 RF, 3 pt: 3 RF)
• a paroxysmal, slight, deep-seated, troublesome sensation in the
orbitotemporal region, com- bined with parasympathetic
symptoms, remained in some cases
• maxillary deafferentation pain (partial peripheral lesion of the
maxillary nerve) was the major complication in 6.1% of patient
• "Because of the small number of patients in our study who
suffered from chronic CH we will not make conclusive remarks
concerning the efficacy of treatment in this subpopulation.”
interventies voor (C)CH (3)
• SPG RFA
• Narouze S et al. (Headache. 2009), 15 CCH who responded to SPG
blocks
• mean attack intensity and frequency was significantly reduced
over 18 months
• 20% (3/15) headache-free for duration of follow-up (18-24
months)
• 46.7% (7/15) reported return to ECH at 18 months
interventies voor (C)CH (4)
• DBS
• 63 pt, 70% response, delay mean 42 days
• because of risk of transient ischemic attack (TIA), hemorrhage, stroke, and
death, peripheral stimulators (ONS, SPG) should always be tried first
• ONS
• Burns et al (Neurology 2009): 14 CCH
• 21% (3/14) > 90% improvement
• 21% (3/14) > 40% improvement
• Magis et al (Headache 2011): 15 CCH
• 80% (11/15) > 90% improvement
• 60% pain free periods
• 36% side shift
• SPG stimulation
• Schydz et al (Cephalgia 2013)
• 25% (7/28): pain relief in > 50% of treated attacks
• 36% (10/28): > 50 % reduction in attack frequency
• 7% (2/28): both