European Academy of Neurology guideline on trigeminal neuralgia

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 Eur...

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Bibliographic Details
Published in:European journal of neurology Vol. 26; no. 6; pp. 831 - 849
Main Authors: Bendtsen, L., Zakrzewska, J. M., Abbott, J., Braschinsky, M., Di Stefano, G., Donnet, A., Eide, P. K., Leal, P. R. L., Maarbjerg, S., May, A., Nurmikko, T., Obermann, M., Jensen, T. S., Cruccu, G.
Format: Journal Article
Language:English
Published: England John Wiley & Sons, Inc 01.06.2019
Subjects:
Baclofen
Botulinum toxin
Botulinum toxin type A
Carbamazepine
Decision making
Decompression
Diagnosis
Gabapentin
guideline
Guidelines
Intravenous administration
Intravenous infusion
Lamotrigine
Lidocaine
Literature reviews
Magnetic resonance imaging
Management
Medical imaging
Medical treatment
Microvasculature
Neuralgia
Neurology
NMR
Nuclear magnetic resonance
Nursing
Oxcarbazepine
Pain
Patients
Pharmacology
Phenytoin
Reflexes
Sequences
Surgery
Trigeminal nerve
trigeminal neuralgia
management
trigeminal neuralgia
guideline
ISSN:1351-5101, 1468-1331, 1468-1331
Online Access:Get full text
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Summary: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 to develop recommendations for a series of questions that are essential for daily clinical management of patients with TN. Methods A systematic review of the literature was performed and recommendations was developed based on GRADE, where feasible; if not, a good practice statement was given. Results The use of the most recent classification system is recommended, 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. Magnetic resonance imaging (MRI), using a combination of three high‐resolution sequences, should be performed as part of the 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, carbamazepine or oxcarbazepine are recommended as drugs of first choice. Lamotrigine, gabapentin, botulinum toxin type A, pregabalin, baclofen and phenytoin may be used either alone or as add‐on therapy. It is recommended 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, it is recommended 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. Click here for the corresponding questions to this CME article.
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ISSN:1351-5101
1468-1331
1468-1331
DOI:10.1111/ene.13950