Symptomatology

The diagnosis of TN can often be derived from the patient history alone. The intensity of the pain is severe, lasting a few seconds and with pain-free intervals in which the pain cannot be provoked (refractory period). Multiple attacks (paroxysms) can be evoked by gently touching the facial skin or oral mucusa, for example during chewing or brushing teeth. It is characteristic that the paroxysmal pain can be provoked from distinct areas (trigger zones) located in one or more divisions of the trigeminal nerve and most often only ipsilateral.103 There is some debate as to whether thermal stimuli are sufficient to provoke the pain, but light tactile and mechanical stimuli are usually described. There is also a periodicity to the pain so there can be pain-free intervals of weeks or months. Words like "shooting," "electric-shock-like," "sharp," and "stabbing" are often used and the McGill Pain Questionnaire can provide important information in this respect. In addition, TN is often associated with poor quality of life, weight loss, depression, and problems related to chewing.104

Somatosensory deficits are not characteristic in the clinical work up of patients, but quantitative sensory tests have been able to demonstrate damage of nerve fiber populations leading to hypoesthesia.105 However, in the individual patient, the QST results do not have major diagnostic implications. Electrophysiological tests, such as laser-evoked potentials and trigeminal somatosensory tests, have also been used and have demonstrated subtle changes in the processing of

sensory inputs.

MRI techniques and angiography are now considered the best options to image the trigeminal ganglion and the adjacent vessels.106 In approximately two-thirds of patients with CTN there is an intimate relationship between the ganglion and the vessels. However, it is also clear that the neurovascular contact is not always associated with TN.107

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