Sir, in view of the recent published guidelines regarding the management of trigeminal neuralgia by the Royal College of Surgeons of England,1 we wanted to bring a recent case to your attention.
An adult male attended an oral medicine department with complaints of an intermittent, shooting, unilateral pain radiating along the left maxilla towards the left nose and upper lip. Episodes could last up to five minutes, and he reported many sleepless nights resulting in fatigue throughout the day. Liaison with his GP had resulted in carbamazepine being prescribed which provided some symptom resolution.
After a sustained period of delay, he eventually attended his oral medicine consultation, describing his pain as having now settled. He reported side effects relating to the carbamazepine. No imaging was arranged. Following a further review, pain severity had now intensified. Oxcarbazepine and then gabapentin were both trialled, neither successful with unpleasant side effects reported.
Given the reoccurrence, an MRI brain scan was requested in line with trigeminal protocol.1 A report revealed a left petrous apex meningioma with mass effect of the left trigeminal nerve cisternal course. His trigeminal neuralgia was diagnosed as being secondary to an intracranial meningioma.2 Surgical resection of this tumour was recommended by his neurologist, which could result in resolution of his facial symptoms.3
Guidelines released by the Royal College of Surgeons of England supports MRI as the imaging modality of choice for screening of trigeminal neuralgia aetiology.1 Up to 10% of patients presenting with trigeminal neuralgia have a secondary causal pathology such as a brain tumour, multiple sclerosis, or vascular malformations.1 These can be identified through neuroimaging.1 The following symptoms, as identified in this case, may indicate intracranial pathology: lack of response to pharmalogical treatments, increase in pain severity over time and continuous interrupted sleep patterns.
Trigeminal neuralgia is often mis-diagnosed as migraines, post-herpetic neuralgia, TMD and dental aetiology.1 This case highlights that even in sustained pain-free episodes, if the patient's history is consistent with trigeminal neuralgia, then there should be a low threshold for requesting imaging. Dental practitioners reviewing patients with confirmed trigeminal neuralgia may wish to confirm whether an MRI of the brain has been performed previously.
Faculty of Dental Surgery of the Royal College of Surgeons of England. Guidelines for the management of trigeminal neuralgia. 2021. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/fds/guidelines/trigemina-neuralgia-guidelines_2021_v4.pdf (accessed February 2023).
Niwant P, Motwani M, Naik S. Atypical trigeminal neuralgia secondary to meningioma. Case Rep Dent 2015; doi: 10.1155/2015/462569.
Castro M R H, Magill S T, Morshed R A et al. Facial pain and sensory outcomes following resection of tumors compressing the trigeminal nerve. J Neurosurg 2021; 136: 1119-1127.
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Roocroft, L., Khan, Z. MRI and trigeminal neuralgia. Br Dent J 234, 294 (2023). https://doi.org/10.1038/s41415-023-5633-z