Joanna M. Zakrzewska

University College London | UCL · Eastman Dental Institute

Background and aims Patients often first present with symptoms of trigeminal neuralgia (TN) to primary care. However, there has been little research to determine whether the diagnosis and management of this condition is carried out according to current guidelines. Furthermore, there is little up-to-date information regarding the prevalence of TN in...

Guidelines for the diagnosis and treatment of patients with trigeminal neuralgia (TN) advocate for a multidisciplinary team approach to improve the care of patients with acute and chronic TN. Evidence-based discussions and decisions are encouraged to establish care pathways for prompt diagnosis and treatment, and long-term outcomes data collection...

Background and objective Trigeminal neuralgia (TN) is a rare chronic neuropathic pain condition of sudden and severe pain, often described as an electric shock. Diagnosis is challenging for non-expert clinicians, particularly in primary care settings. We wanted to identify and assess the diagnostic accuracy of existing screening tools for TN and or...

Aims: To understand, from the patient perspective, the meaning of living with trigeminal neuralgia (TN) and what the patient-desired outcomes of treatment are. Methods: A qualitative study involving focus group work with 14 participants with a diagnosis of TN was conducted. The discussions were recorded and transcribed verbatim and analyzed usin...

Background Trigeminal neuralgia is an episodic severe neuralgic pain and can be managed both medically and surgically. If possible, this should be directed by a Multidisciplinary Team (MDT) of specialised surgeons, physicians, dentists, psychologists and specialist nurses with access to all treatment modalities, which enables patients to make an in...

Background: Trigeminal Neuralgia (TN) is an excruciating unilateral facial pain, which negatively affects patient's quality of life. Historically, it has been difficult to compare treatment efficacy due to the lack of standardized outcomes. In addition, patients' perspective has seldomly been acknowledged. The aim of this study was to reach consen...

Background: Trigeminal neuralgia is an episodic severe neuralgic pain and can be managed both medically and surgically. If possible, this should be directed by a Multidisciplinary Team (MDT) of specialised surgeons, physicians, dentists, psychologists and specialist nurses with access to all treatment modalities, which enables patients to make an i...

Aims: To evaluate About Face, a pain management program aimed at increasing quality of life in adults living with persistent facial pain through psychology- and physiotherapy-based skill development. Methods: A total of 90 patients attended a six-session program with a 1-month follow-up between 2015 and 2019. Patients filled out self-reported ou...

International classification systems define trigeminal neuralgia (TN) as a disorder characterized by recurrent, unilateral, brief electric shock-like pains, abrupt in onset and termination, limited to the trigeminal nerve territory, and triggered by innocuous stimuli. The clinical diagnosis is based on history. TN may manifest as purely paroxysmal...

The greatest challenges to the management of trigeminal neuralgia and other cranial neuralgias result from gaps in our understanding of the mechanisms generating and maintaining the symptoms, patient assessment, methods for measuring outcomes, lack of adequately powered controlled trials, and inherent limitations of drug and surgical treatments. Th...

This chapter explores the prevalence and aetiology of trigeminal neuralgia and its variants. A summary review of prevalence studies, both population-based and hospital studies, is included. Studies showed that the prevalence of trigeminal neuralgia ranges between 0.1% and 0.7%. A lack of consistency in disease definition caused some studies to repo...

The term primary trigeminal neuralgia is used for classical and idiopathic trigeminal neuralgia as no cause other than compression of the trigeminal nerve is noted on magnetic resonance imaging in the classical cases. The shooting electrical pain is unilateral, evoked by light touch, and occurs as single or multiple episodes of pain lasting seconds...

Trigeminal neuralgia has been known for centuries but the first descriptions that remain valid today are those by John Fothergill in 1783. The chance naming of the condition as a form of epilepsy led to the use of a wide range of antiepileptic drugs which are still being utilized. Since 1730, surgical techniques have been evolving. Peripheral treat...

The diagnosis of a cranial neuralgia or neuropathy is clinical and rests on a detailed oral history. A working diagnosis can be obtained using eight yes-or-no questions. Clinical examination apart from sensory testing serves to rule out other facial pain conditions. Magnetic resonance imaging is essential as an aetiological investigation but requir...

By general consensus, the first-line treatment for trigeminal neuralgia is pharmacological. The two first drugs of choice are carbamazepine and oxcarbazepine, both voltage-gated sodium channel blockers that stabilize the hyperexcited neural membrane and inhibit repetitive firing. Although highly effective in controlling trigeminal neuralgia paroxys...

When patients with trigeminal neuralgia can no longer achieve adequate pain relief and quality of life becomes poor, surgical procedures need to be considered. There is a lack of high-quality evidence to support surgical treatments so all the recommendations are based on low-grade evidence of prospective or retrospective series. Microvascular decom...

Trigeminal neuralgia and other cranial neuralgias comprise a group of facial pain conditions, characterized by disabling pain attacks that selectively respond to specific treatments. Although not as common as migraine they affect over 1% of the population. The spectrum of cranial neuralgias is wide and as a consequence, the conditions are managed b...

Background Trigeminal neuralgia (TN) is a relatively rare condition which has a profound impact not only on the patient but also on those around them. There is no cure for TN, and the management of the condition is complex. The most effective forms of treatment are either through medication, neurosurgery, or combination of the two. Each option has...

Trigeminal Neuralgia

Correspondence: N. Tchantchaleishvili The Journal of Headache and Pain 2021, 22(Suppl 2):P0430 Background Trigeminal Neuralgia (TN) is an episodic severe neuralgic pain resulting in significant impact on quality of life. It can be managed both medically and surgically. Aim To review all patients who attended a joint neurosurgeon and physician...

Aim: Multiple sclerosis (MS) is well recognized as a secondary cause for trigeminal neuralgia (TN). In this case series, we detail the management of all the patients with TN and MS (pwTNMS) presenting to a specialist unit. Materials & methods: A prospective patient database was used to extract key clinical data on pharmacological, psychometric and...

Trigeminal neuralgia (TN) is a highly disabling disorder characterised by very severe, brief and electric shock like recurrent episodes of facial pain. New diagnostic criteria, which subclassify TN on the basis of presence of trigeminal neurovascular conflict or an underlying neurological disorder, should be used as they allow better characterisati...

Background: Trigeminal neuralgia (TN) is a rare condition for which there are multiple treatment options available. To date, there has been difficulty in comparing the outcomes of treatment due to the variety of patient-reported outcome measures (PROMs) and their inadequate psychometric testing. The aim of this review was to assess the psychometri...

What is persistent pain? How do we communicate pain, not only in words but in visual images and gesture? How do we respond to the pain of another, and can we do it better? Can explaining how pain works help us handle it? Encountering Pain shares leading research into the potential value of visual images and non-verbal forms of communication as me...

Aims: To test the feasibility and acceptability of a customized six-session cognitive behavioral therapy (CBT) group intervention for adults with recurrent trigeminal neuralgia (TN). Methods: Fifteen participants with TN were recruited from a specialist facial pain unit in London, United Kingdom. The effects of the group intervention were evalua...

Background Trigeminal neuralgia (TN) causes severe episodic, unilateral facial pain and is initially treated with antiepileptic medications. For patients not responding or intolerant to medications, surgery is an option. Methods In order to expand understanding of the pain-related burden of illness associated with TN, a cross-sectional survey was...

Trigeminal neuralgia is a very painful neurological condition with severe, stimulus-evoked, short-lasting stabbing pain attacks in the face. The past decade has offered new insights into trigeminal neuralgia symptomatology, pathophysiology, and treatment, leading to a change in the classification of the condition. An accurate diagnosis is crucial b...

Background: Trigeminal neuralgia (TN) is an orofacial condition defined by reoccurring, spontaneous, short-lived but excruciating stabbing pain. Pharmacological interventions constitute the first-line treatment for TN, with antiepileptic drugs commonly prescribed. People treated for TN pain with antiepileptic drugs describe cognitive and motor dif...

Purpose: Vixotrigine (BIIB074) is a voltage- and use-dependent sodium channel blocker. These studies will evaluate the efficacy and safety of vixotrigine in treating pain experienced by patients with trigeminal neuralgia (TN) using enriched enrollment randomized withdrawal trial designs. Patients and methods: Two double-blind randomized withdraw...

Orofacial pain is a complex problem and affects up to 7% of the population. Although trigeminal neuralgia has been considered the prime neuralgic condition in the facial region, other forms of neuropathic pain are now being more frequently recognized and require recognition and a different management approach. Many patients with chronic orofacial p...

Background: Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock-like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measure...

Aims: To investigate how photographic images (Pain Cards) co-created by an artist and chronic pain patients could be used in groups of patients with burning mouth syndrome to facilitate characterization of their pain and its impact on quality of life. Methods: Ten groups of patients with burning mouth syndrome attending a 2.5-hour information se...

Background and Aims Patients with trigeminal neuralgia (TN) can be overwhelmed with information they are given when first seen in a specialist secondary care clinic. The purpose of this study is to evaluate the extent to which a telephone service provided by the clinical nurse specialist (CNS) with independent prescribing rights improves patient ma...

Trigeminal neuralgia (TN) and Trigeminal autonomic cephalalgias (TACs) can cause severe facial pain. The differential diagnosis can be very challenging as both present with a sudden, usually unilateral, severe, recurrent pain in the distribution of one or more branches of the trigeminal nerve; with TACs including one or more autonomic symptom. A li...

Trigeminal neuralgia is one of the most severe facial pains that patients can experience. This unpredictable, episodic pain, mostly unilateral in the distribution of the trigeminal nerve, results in recurrent shooting pain lasting for seconds to minutes. It is light touch provoked and therefore prevents patients from eating and touching their face,...

Why is the simple act of listening to a patient’s story of suffering so important?

The management of orofacial pain is considered to be within the remit of oral and maxillofacial surgery (OMFS). In this study we aimed to provide an overview of the healthcare "journey" of a group of patients referred to a specialist unit with "complex" non-temporomandibular orofacial pain. We retrospectively reviewed all those who were referred ov...

Background Trigeminal neuralgia (TN) can have a significant impact on wellbeing and quality of life. Limited data exist for treatments that improve TN pain acutely, within 24 h of administration. This systematic review aims to identify effective treatments that acutely relieve TN exacerbations. Methods We searched Medline and Cochrane Central Regi...

Objectives: The commonest secondary cause for trigeminal neuralgia (TN) is multiple sclerosis (MS) and little is known about this group of patients in terms of their presentation and treatments. We compared patients with TN and MS (pwTNMS) with a cohort of patients with primary TN, who had been referred to the same specialist unit, both in terms o...

Background and purpose: 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 the management of TN. The European Academy of Neurology asked an expert panel...

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 recom...

Background This study aimed to describe recruitment challenges encountered during a phase IIa study of vixotrigine, a state and use-dependent Nav1.7 channel blocker, in individuals with trigeminal neuralgia. Methods This was an international, multicenter, placebo-controlled, randomized withdrawal study that included a 7-day run-in period, a 21-day...

Background: Better tools are required for the earlier identification and management of orofacial pain with different aetiologies. The painDETECT questionnaire is a patient-completed screening tool with utility for identification of neuropathic pain in a range of contexts. 254 patients referred from primary care for management of orofacial pain atte...

Background: Management strategies for the recurrence of trigeminal neuralgia after microvascular decompression include repeat procedures, medical management or no further therapy. No consensus exists as to which strategy is best for pain relief. The aim of this study was to determine the characteristics of patients with recurrences after microvascu...

The challenge for those treating or witnessing pain is to find a way of crossing the chasm of meaning between them and the person living with pain. This paper proposes that images can strengthen agency in the person with pain, particularly but not only in the clinical setting, and can create a shared space within which to negotiate meaning. It draw...

Background and objective The Penn Facial Pain Scale (Penn-FPS) was originally developed as a supplemental module to the Brief Pain Inventory Pain Interference Index (BPI-PII) in order to fully assess the impact of trigeminal neuralgia (TN) pain on patients’ health-related quality of life (HRQoL). The current objective is to create and establish the...

Background and aim: Trigeminal neuralgia (TN) is a rare orofacial disorder characterized by severe unilateral paroxysmal pain in the region of the fifth cranial nerve. Clinical guidelines recommend carbamazepine (only US Food and Drug Administration-approved drug for TN) and oxcarbazepine as first-line therapies. We utilized the US Truven Health M...

Background: Side effects of anti-epileptic drugs (AEDs) have not been adequately documented in trigeminal neuralgia and its variants. The aim of this observational cross-sectional study was to compare the A-B Neuropsychological Assessment Schedule (ABNAS), which measures cognitive side effects to the Adverse Events Profile (AEP), which looks at a...

Pain is common and difficult to communicate or reduce into the verbal or numerical scales commonly used in clinical practice. Some academics have argued that pain resists description in language while others have argued conversely that it generates language. This chapter identifies the limitations of verbal language and current standardized scores...

Background: Microvascular decompression (MVD) and partial sensory rhizotomy (PSR) provide longstanding pain relief in trigeminal neuralgia (TN). Given their invasiveness, complications can result from such posterior fossa procedures, but the impact of these procedures and their complications on patient-reported outcome measures (PROM), such as qual...

Background and objective: Patients with trigeminal neuralgia (TN) and multiple sclerosis (MS) are often treated with medications or a surgical procedure. However, there is little evidence that such treatments result in 50% pain reduction and improvement in quality of life. The aim of this systematic review is to evaluate the clinical effectiveness...

Pain is common and difficult to communicate or reduce into the verbal or numerical scales commonly used in clinical practice. Some academics have argued that pain resists description in language while others have argued conversely that it generates language. This chapter identifies the limitations of verbal language and current standardized scores...

TN is a relatively rare condition defined as “a sudden unilateral severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve” IASP [1].

Aim Appreciate how current understanding of the pathophysiology of trigeminal neuralgia has impacted on treatments. The ignition theory puts forward the hypothesis that some form of trauma to the trigeminal nerve at any level results in abnormal firing of neurons which result in episodic pain. It is likely that patients with trigeminal neuralgia ha...

A variety of treatment outcomes in chronic pain are influenced by patient–clinician rapport. Patients often report finding it difficult to explain their pain, and this potential obstacle to mutual understanding may impede patient–clinician rapport. Previous research has argued that the communication of both patients and clinicians is facilitated by...

Background and aims: Patient-completed screening tools may aid diagnosis of orofacial pain in non-specialist centres. We aimed to evaluate the diagnostic accuracy of patient- completed screening tools in a hospital-based cohort of patients referred for orofacial pain. Methods: Prior to first appointment at a hospital facial pain clinic, patients we...

A review by Professor Joanna Zakrzewska who is the head of the Medical Advisory Board for the Trigeminal Neuralgia Association UK (TNA UK)

Premise Facial pain refers to a heterogeneous group of clinically and etiologically different conditions with the common clinical feature of pain in the facial area. Among these conditions, trigeminal neuralgia (TN), persistent idiopathic facial pain, temporomandibular joint pain, and trigeminal autonomic cephalalgias (TAC) are the most well descri...

Background: Current standard of care for trigeminal neuralgia is treatment with the sodium channel blockers carbamazepine and oxcarbazepine, which although effective are associated with poor tolerability and the need for titration. BIIB074, a Nav1.7-selective, state-dependent sodium-channel blocker, can be administered at therapeutic doses without...

There is a lack of prospective systematic studies on the clinical characteristics of pain in trigeminal neuralgia (TN) as well as its 'psychosocial burden'. Patients with idiopathic TN were categorised into three sub-types (n = 225). Group 1 (n= 155, 68.9%) had TN without concomitant pain, Group 2 (n=32, 14.2%) had TN with intermittent concomitant...

Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review...

The mucocutaneous pain syndromes (MCPs) typically involve the head, neck and mouth. Genital dysaesthetic syndromes (vulvodynia, vestibulodynia, penoscrotodynia) are also common and are discussed in this chapter, as well as in specific genital chapters. For many MCPs no organic cause for their disease can be identified (with the exception of post‐he...

Objectives: Diagnostic screening tools can serve as valuable aids for triaging of patients, for diagnostic and research purposes. This study evaluates the utility of validated patient pain reported screening tools in a hospital-based cohort of orofacial pain patients. Methods: A prospective study was conducted at a London dental teaching hospital....

Persistent or chronic idiopathic facial pain, often called atypical facial pain, is often used as a diagnosis of exclusion. It is chronic pain in a nonanatomically distributed area of the face and mouth that can be episodic or continuous and described as a nagging dull pain that at times is severe. It is associated with other chronic pain condition...

Key points: 1. There is no high quality comparative effectiveness research for surgery versus pharmacological management or for different surgical techniques. 2. High quality evidence (randomised controlled trials) is required to inform routine decision making for patients with TN and their consultants. 3. The design and conduct of surgery trials u...

Trigeminal neuralgia (TN) is an exemplary condition of neuropathic facial pain. However, formally classifying TN as neuropathic pain based on the grading system of the International Association for the Study of Pain is complicated by the requirement of objective signs confirming an underlying lesion or disease of the somatosensory system. The lates...

Aim: To assess the quality of referral letters to a facial pain service and highlight the key requirements of such letters. Method: The source of all referral letters to the service for five years was established. For one year the information provided in 94 referrals was assessed. Using a predetermined checklist of essential information the refe...

The evidence base for drug management for these rare conditions is low due to the lack of high-quality randomised controlled trials (RCTs). Carbamazepine and oxcarbazepine have been shown to be highly effective in trigeminal neuralgia and are considered to be the first-line drugs. However, they do have significant side effects and their efficacy di...

Adverse effects of drugs are poorly reported in the literature . The aim of this study was to examine the frequency of the adverse events of antiepileptic drugs (AEDs), in particular carbamazepine (CBZ) and oxcarbazepine (OXC) in patients with neuralgiform pain using the psychometrically tested Liverpool Adverse Events Profile (AEP) and provide cli...

Background Trigeminal Neuralgia (TN) is a serious health problem, causing brief, recurrent episodes of stabbing or burning facial pain, which patients describe as feeling like an electric shock. The consequences of living with the condition are severe. There is currently no cure for TN and management of the condition can be complex, often delayed b...

Trigeminal neuralgia is a rare cause of episodic unilateral facial pain and often in the initial presentation dental causes need to be eliminated, as it frequently presents in the lower trigeminal divisions. The pain description is characteristic of electric shock-like pain that is light-touch provoked, paroxysmal, and occurring daily; the conditio...

Abstract Background: Visual images may facilitate communication of pain in consultations. Objectives: In order to test whether photographic images of pain enrich the content and/or process of pain consultation, we compared patients’ and clinicians’ ratings of the consultation experience. Methods Photographic images of pain previously co-created by...