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Eur J Neurol. 2019 Mar 12. doi: 10.1111/ene.13950. [Epub ahead of print]

EAN guideline on trigeminal neuralgia.

Author information

1
Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, 2600, Glostrup, Denmark.
2
Pain Management Centre, National Hospital for Neurology & Neurosurgery, 25 Cleveland Street, London, W1T 4AJ.
3
Eastman Dental Hospital, UCLH NHS Foundation Trust, UK.
4
Trigeminal Neuralgia Association UK, PO Box 234, Oxted, Surrey, RH8 8BE, UK.
5
Clinic of Neurology, University of Tartu, Tartu, Estonia.
6
Department of Human Neuroscience, Sapienza University, viale Università 30, 00185, Rome, Italy.
7
Headache and Pain Department, CHU La Timone, APHM, Marseille, France.
8
Department of Neurosurgery, Oslo university hospital-Rikshospitalet, Oslo, Norway.
9
Institute of Clinical Medicine, Faculty of medicine, University of Oslo, Oslo, Norway.
10
Department of Neurosurgery, Faculty of Medicine of Sobral, Federal University of Ceará, Sobral, Brazil.
11
University of Lyon 1, Lyon, France.
12
Department of Systems Neuroscience, Universitäts-Krankenhaus Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany.
13
Neuroscience Research Centre, The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, UK.
14
Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany.
15
Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, University of Aarhus, 8000, Aarhus C, Denmark.

Abstract

BACKGROUND:

Trigeminal neuralgia (TN) is an extremely painful condition, which can be difficult to diagnose and treat. In Europe, TN-patients are managed by many different specialities. Therefore, there is a great need for comprehensive European guidelines for management of TN. The European Academy of Neurology asked an expert panel to develop recommendations for a series of questions that are essential for daily clinical management of patients with TN.

METHODS:

We performed a systematic review of the literature and developed recommendations based on GRADE, where feasible, if not a good practice statement was given.

RESULTS:

We recommend the use of the most recent classification system, which diagnoses TN as primary TN, either classical or idiopathic depending on the degree of neurovascular contact, or as secondary TN caused by pathology other than neurovascular contact. An MRI, using a combination of three high-resolution sequences, should be performed as part of work up in TN patients, because no clinical characteristics can exclude secondary TN. If MRI is not possible, trigeminal reflexes can be used. Neurovascular contact plays an important role in primary TN, but demonstration of a neurovascular contact should not be used to confirm the diagnosis of TN. Rather, it may help to decide if and when a patient should be referred for microvascular decompression. In acute exacerbations of pain, intravenous infusion of fosphenytoin or lidocaine can be used. For long-term treatment we recommend carbamazepine or oxcarbazepine as drugs of first choice. Lamotrigine, gabapentin, botolinum toxin type A, pregabalin, baclofen and phenytoin may be used either alone or as add-on therapy. We recommend that patients should be offered surgery if pain is not sufficiently controlled medically or if medical treatment is poorly tolerated. Microvascular decompression is recommended as first-line surgery in patients with classical TN. No recommendation can be given for choice between any neuroablative treatments or between them and microvascular decompression in patients with idiopathic TN. Neuroablative treatments should be the preferred choice if MRI does not demonstrate any neurovascular contact. Treatment for patients with secondary TN should in general follow the same principles as for primary TN. In addition to medical and surgical management, we recommend that patients are offered psychological and nursing support.

CONCLUSIONS:

Compared with previous TN guidelines, there are important changes regarding diagnosis and imaging. These allow better characterization of patients and help in decision making regarding the planning of medical and surgical management. Recommendations on pharmacological and surgical management have been updated. There is a great need for future research on all aspects of TN, including pathophysiology and management. This article is protected by copyright. All rights reserved.

KEYWORDS:

guideline; management; trigeminal neuralgia

PMID:
30860637
DOI:
10.1111/ene.13950

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