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Trigeminal Neuralgia (TN) and Multiple Sclerosis (MS)

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Incidence

  • TN may rarely be the first symptom of MS, but usually does not begin until about 11 years after the onset of MS.
  • When TN is diagnosed in anyone under the age of 40, MS is suspected and should be ruled out.
  • TN with MS is 18% more likely to be bilateral. It usually begins on one side and after years occurs on the other. It is preferable to treat each side individually, while guarding against having numbness on both sides.
  • TN with MS is more likely to be atypical pain – dull, burning & constant rather than electric bolt type pain.
  • 1-2% of MS patients develop TN.

Medication

  • Baclofen is usually well tolerated.
  • Tegretol, Dilantin, Trileptal, etc. All the anticonvulsants that are used for typical TN can be used with MS, but they may further compromise existing neurological problems.
  • A study by M. Zvartau-Hind, MD, et al, as reported in Neurology, Nov 2000, showed successful treatment of 6 TN/MS patients with Topomax (Topiramate) with minimal side effects.
  • A study by Leandri, Massimo, et al, in the Journal of Neurology, 2000, reported the successful treatment of 18 TN/MS patients with Lamictal (Lamotrigine), and with minimal side effects.
  • Evers, Stefan, et al, in the Journal of Neurology, 2003, reported that Cytotec (Misoprostol), an anti-inflammatory drug was effective in treating TN/MS.
  • Drugs work by different processes and by affecting different nerve sites, so drug combinations may be beneficial. By giving two medications to control pain, smaller doses of each can be utilized, thus decreasing dose-related adverse effects. These points were illustrated by a study done by Solaro, C., et al in an original paper from European Neurology, 2000 where Neurontin (Gabapentin) was given with Lamictal or Tegretol.

Treatment

  • Microvascular Decompression (MVD) may be appropriate if a blood vessel is shown to be compressing the trigeminal nerve. In an article which was published in the Journal of Neurology Neurosurgical Psychiatry, 2000, Dr. Giovanni Broggi states that he would not withhold an MVD from any patient with intractable pain even with a negative MRI/MRA.
  • Glycerol injection
  • Radiofrequency Rhizotomy
  • Balloon Compression
  • Initial success rates for all treatments are less with TN/MS and patients are more likely to have a reoccurrence of pain after treatment.

Research and Tidbits

  • Research is being done to try to stop damage to the myelin sheath, or to help regeneration after the damage is done by utilizing medications, nutrition, and gene therapy.
  • A study of MS patients with loss of facial sensation was printed in Archives of Neurology, Jan 2001. In 5 patients, unique lesions were found on the trigeminal nerve root. Similar lesions have been seen during animal studies with Herpes Simplex Virus (HSV), and continued study will be needed to determine the significance—whether a HSV infection causes these lesions, or whether a disease related inflammatory response triggers the HSV.
  • An incidence of face pain and MS due to a rare headache disorder, Trigeminal autonomic cephalgia’s (TAC’s), was reported in Cephalalgia, 2004 by R. Dave and A. Al-Din. The pain, which was reported to be shooting, stabbing, piercing intermittent and constant in different locations is accompanied by reddening and tearing of the eye, and was initiated by triggers as in typical TN. A MS lesion of the hypothalamus is thought to be the causative agent, and this patient was pain free after being treated with Lamictal.
  • In the June 1999 issue of Archives of Neurology, Dr. Mathias Hartmann, et al discuss a case of TN pain in an MS patient that was triggered by noise, such as a ringing telephone. One of their possible explanations for this phenomenon was that lesions on the pons allowed damaged auditory (hearing) and trigeminal nerve endings to cross over their impulses.
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