In approaching any patient with symptoms referable to the trigeminal system, it is necessary to localize the pathological process; identify associated symptoms; determine prognosis; and provide relief from pain, discomfort, and functional disability. Regardless of etiology, a detailed and directed neurological examination most often yields the correct anatomical localization.
Once determined that the likely etiology is, for example, within the brain, brain stem, or cranial vault, a rational first step is MRI of the brain with and without gadolinium contrast. Fine cuts may be obtained through the orbits, using fat saturation sequences to diminish intraorbital fat artifact. Similarly, dedicated coronal images may be taken to focus on the cavernous sinus. Once appropriate neuro-imaging has been performed, other diagnostic studies such as lumbar puncture may be indicated, especially if infectious or carcinomatous processes are suspected. Electrophysiologic studies such as somatosensory evoked potentials may be somewhat helpful in peripheral trigeminal neuropathies. In either central or peripheral causes, neurosurgical consultation may be warranted, especially when there is compression of the trigeminal nerve roots or branches.
Prompt relief of the severe pain associated with this disorder must not be neglected. Both medical and surgical approaches should be considered when appropriate. Over
the short term, nonsteroidal anti-inflammatory agents and narcotics may provide symptomatic relief. In patients with refractory neuropathic pain, treatment with tricyclic compounds such amitriptyline, nortriptyline, or carbamazepine may be indicated.
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