Lightning pain

Introduction Trigeminal neuralgia has a sudden onset of pain, manifested as a point in the face, mouth and jaw, and suddenly a sharp lightning-like short-term pain. First reported by Nicolas Andri of France in 1756. Because most of the seizures are accompanied by facial muscle twitching, it is called "painful convulsions." It refers to a recurrent episode of transient paroxysmal severe pain that is confined within the trigeminal innervation. Can be divided into primary and secondary.

Cause

The etiology and pathogenesis of primary (idiopathic) trigeminal neuralgia are unclear. In most cases, there is no V-shaped organic disease of the cranial or central nervous system, and the Gasser ganglion has degenerative or fibrotic changes. However, the difference in weight and weight is too great to be considered as the cause.

Although the etiology of primary trigeminal neuralgia is not clear, there is no unified understanding, and from the perspective of modern medicine, its pathogenesis may be a causative factor, causing demyelination changes in the sensory root half-month and adjacent motor branches. Some studies have suggested that most patients with primary trigeminal neuralgia have abnormal oppression of the nerves from the skull base.

It has been clinically proven that some of the so-called primary trigeminal neuralgia can actually find the cause, such as the vascular hardening of the supply nerve, the compression of the ectopic blood vessels, the thickening of the arachnoid and the passage of the nerve through the surgery. Periostitis, narrow bone holes, etc., causing nerve root compression.

1. The cause of primary trigeminal neuralgia In the case of trigeminal neuralgia, peripheral nerves and central nervous system are involved in the generation and transmission of pain. Therefore, according to modern clinical practice and animal test results, the causes of primary trigeminal neuralgia are as follows. Several doctrines.

(1) Peripheral pathogen theory: lesions in any part of the trigeminal nerve endings to the brainstem nucleus can stimulate the trigeminal nerve, causing physiological dysfunction and organic changes in the central nervous system, resulting in a matrix within the distribution of the trigeminal nerve. a severely painful doctrine.

(2) Central etiology: the brain core of the trigeminal nervous system, the trigeminal nucleus, the thalamus and the cerebral cortex can cause trigeminal neuralgia due to the stimulation of the surrounding lesions and the nociceptive stimulation of the central body itself.

(3) Allergic theory: In 1967, according to the sudden onset and reversibility of trigeminal neuralgia, Hanes suggested that trigeminal neuralgia may be a disease associated with allergies.

(4) Viral infection theory: The cerebral cortex is the highest center of the whole body feeling. It has long been determined that the pain caused by the lesions in any part of the trigeminal nervous system is reflected by the cerebral cortex. Viral infections such as herpes and herpes simplex can invade the cerebral cortex of the trigeminal nerve along the pathway of the trigeminal nervous system, causing pain in the trigeminal nerve.

(5) Family genetics: It has been reported in the clinic that 6 of 7 family brothers and sisters have trigeminal neuralgia, and 2 of them suffer from bilateral pain. In another family, the mother and 3 of the 6 children had trigeminal neuralgia, 2 of whom had bilateral pain. It is believed that trigeminal neuralgia may be related to family inheritance. However, most scholars believe that the relationship between this disease and genetic factors is not related to human race.

(6) Comprehensive etiology: None of the above-mentioned theories can explain the cause of trigeminal neuralgia. So Dott (1951) thought that the cause of trigeminal neuralgia in the brainstem, action or triggering the trigger point can cause a short impulse to quickly superimpose in the brainstem, causing severe pain episodes.

2. The etiology of secondary trigeminal neuralgia In recent years, through clinical practice and research, especially the application of neuromicrosurgery and the continuous improvement of surgical methods, the understanding of the etiology and incidence of secondary trigeminal neuralgia has Have a deeper understanding and understanding. It was found that various lesions at the site of the trigeminal nervous system or adjacent sites can cause trigeminal neuralgia. The most common causes are intracranial and skull base tumors, vascular malformations, arachnoid adhesions, and multiple sclerosis.

an examination

Related inspection

X-ray lipiodol imaging head palpation

According to the paroxysmal pain in the trigeminal innervation area and its clinical features, the diagnosis of primary and secondary trigeminal neuralgia is not difficult to determine.

1. Paroxysmal severe pain in the trigeminal innervation area: knife cutting, burning.

2. Clinical features: sudden, trigger point, burst, repeated; painful convulsions.

3. Determine primary and secondary. Primary trigeminal neuralgia, objective examination of multiple trigeminal nerve function defects and other localized neurological signs.

Differential diagnosis

In addition to secondary trigeminal neuralgia, attention should be paid to the identification of the following diseases.

Toothache

Toothache is also a very painful disease. Sometimes, especially in the early stage of the disease, it often goes to the oral cavity and is misdiagnosed as toothache. Many patients remove their teeth and even remove the affected teeth, but the pain can not be alleviated. General toothache is characterized by persistent dull pain or jumping pain, limited to the gingival part, not to other parts, no facial skin allergic area, not exacerbated by external factors, but patients do not dare to chew with teeth, X-ray examination or CT examination can identify toothache.

2. Trigeminal neuritis

Can be caused by acute maxillary sinusitis, influenza, frontal sinusitis, mandibular osteomyelitis, diabetes, syphilis, typhoid, alcoholism, lead poisoning and food poisoning. There is a history of inflammatory infections, a short history, and persistent pain. The localization of the branches of the compression infection can aggravate the pain, and there is a feeling of diminished or allergic to the trigeminal nerve on the affected side. May be associated with movement disorders.

3. The characteristics of patients with intermediate neuralgia and intermediate neuralgia:

(1) The nature of pain: it is a paroxysmal burning pain, which lasts for a long time, several hours, and the short is also a few minutes.

(2) Pain area: mainly located on one side of the external auditory canal, auricle and mastoid, etc., severe cases can be radiated to the same side, tongue, pharynx and occipital.

(3) Accompanying symptoms: localized with herpes zoster, localized facial paralysis, taste and hearing changes.

4. Chinic neuralgia The cause of this disease is unknown. Most people think that paranasal sinusitis invades the sphenopalatine ganglion.

(1) Pain site: the deep part of the nasal cavity, sphenoid sinus, ethmoid sinus, hard palate, gums and eyelids in the distribution area of the sphenopalatine ganglion. The range of pain is wider.

(2) Pain nature: Pain is a burning or drilling-like severe pain, with persistent or paroxysmal aggravation or periodic recurrent episodes, usually lasting for several minutes to several hours. Accompanied by swelling of the nasal mucosa of the affected side, nasal congestion, nasal secretions increased, mostly serous or mucinous. Can be accompanied by tinnitus, deafness, tears, photophobia and burning and tingling of the jaw skin. Pain can occur from the teeth, nose, eyelids, and eyeballs, and then to the gums, forehead, ears, and mastoids, all of which are lateral. Severe cases radiate to the same side of the neck, shoulders and hands, and there may be tenderness in the eyelids.

(3) Age of onset: often between 40 and 60 years old, more women.

(4) The disease can be blocked with 1% procaine for sphenopalatine nerve or 2% to 4% tetracaine for nasal sphenopalatine ganglion surface anesthesia, which can relieve pain and confirm the diagnosis.

5. Migraine Migraine, also known as cluster headache, is a clinical syndrome characterized by vasomotor dysfunction of the head. The cause is more complicated and has not yet been fully elucidated. But it is related to family, endocrine, allergic reactions and mental factors. Clinical manifestations:

(1) Adolescent women are more common and have more family history.

(2) Causes of induction: Most induced during fatigue, menstruation, and emotional agitation, there are signs before each episode, such as blurred vision, flash, dark spots, eye swelling, illusion and hemianopia. The symptoms of aura can last from a few minutes to half an hour.

(3) The nature of the pain is severe headache, which is pulsating pain, tingling and tearing pain or pain. Repeated episodes, once a day or weeks, months or even years. Accompanied by nausea, vomiting, feeling of bowel movements, tears, pale or flushing. Fatigue and sleepiness after the attack.

(4) When the body is examined, the twitching of the superficial artery is obviously enhanced, and the pain can be relieved when the body is pressed. The use of antihistamines in the onset of aura can relieve symptoms.

(5) Migraine also has common type, special type (eye muscle paralysis, abdominal type, basilar artery type) migraine, which need to be identified.

6. Glossopharyngeal neuralgia This disease is divided into two major categories: primary and secondary. It is a paroxysmal pain in the area of the glossopharyngeal nerve. The age of onset is more than 40 years old, and the nature of pain is similar to trigeminal neuralgia. Clinical manifestations have the following characteristics.

(1) The cause may be related to the inferior cerebellar artery and vertebral artery compression nerve entry area. In addition, it may be caused by tumor, inflammation, cyst, nasopharyngeal tumor or styloid process in the cerebellar pons.

(2) The pain site is in the affected side of the tongue, throat, tonsil, deep ear and posterior mandible, sometimes with deep ear pain as the main performance.

(3) The nature of the pain is a sudden onset, which suddenly stops. Each episode lasts for a few seconds or tens of seconds, rarely exceeding 2 minutes. It also resembles severe pain in acupuncture, knife cutting, burning, tearing and electric shock. If the secondary pain is long or persistent, the cause and trigger point are not obvious, and the night is heavier.

(4) The cause is often induced by swallowing, chewing, talking, coughing, and yawning.

(5) More than 50% have a trigger point, the site is mostly in the posterior pharyngeal wall, the tonsil tongue root, etc., a few in the external auditory canal. If it is secondary, the trigger point may not be obvious, and the symptoms of glossopharyngeal nerve damage, such as soft palsy, soft palate and pharyngeal sensation diminished or disappeared.

(6) Other symptoms: When you swallow, you often cause pain. Although there is no pain during the intermittent period, you are afraid to eat or care to enter the juice because of fear of causing pain. The patient becomes thinner and even dehydrated due to less intake of water. , pharyngeal discomfort, arrhythmia and hypotension fainting.

(7) There is no positive sign in the nervous system. If it is secondary, it may have pharyngeal, phlegm, 1/3 of the tongue, sensation diminished, taste loss or disappearance, and parotid gland secretion disorder. There may also be symptoms of adjacent cranial nerve damage, such as cranial nerve damage and Horner's sign on days 9, 10 and 11.

7. Paranasal sinusitis or tumor

Patients with maxillary sinus, maxillary sinus, and ethmoid sinus can cause head and face pain. Special attention should be paid to the identification: nasal examination, whether the two sides are the same, check the tender points of each sinus; whether there is mucus or pus in the nasal cavity; the onset of pain is not obvious, this point is more significant in the frontal sinus cancer; The affected side is sometimes swollen; the maxillary sinus and frontal sinus are examined for light transmission; X-ray examination can help to confirm the diagnosis.

8. Tumors near the half-moon ganglion

Tumors at the half-moon ganglion and cerebellar pons are not uncommon, such as acoustic neurofibroma, cholesteatoma, hemangioma, meningioma or dermoid cysts. The pain caused by these tumors is generally not very serious, unlike trigeminal nerves. It hurts like a pain. In addition, there may be abduction of nerve palsy, facial nerve palsy, tinnitus, dizziness, hearing loss, loss of trigeminal sensation, and other symptoms of intracranial tumors such as headache, vomiting, and optic nerve head edema. X-ray examination of the skull base, sometimes bone destruction in the tip of the rock bone or bone destruction in the inner ear canal area. CT and X-ray examination can help diagnose.

9. Knee ganglion pain

Before the tympanic nerve is issued, the geniculate ganglion emits a superficial nerve, which supplies the lacrimal gland with parasympathetic nerve fibers and the secretion of the lacrimal gland. The middle nerve is mainly responsible for the 2/3 taste of the tongue and the sensation of the eardrum and the posterior wall of the external auditory canal. There are also some secretions of the submandibular gland, sublingual gland, and mucous glands of the mouth and nasal cavity. Knee ganglion neuralgia is paroxysmal, but the pain in the ear is deep in the ear, radiating to the eyes, cheeks, nose, lips, etc., and there is a "trigger point" on the posterior wall of the external auditory canal. These patients have multiple facial paralysis or facial convulsions, and sometimes herpes and loss of taste occur on the soft palate, in the tonsil socket, and in the external auditory canal.

10. Other facial neuralgia

Such as many eye diseases, glaucoma, refractive error and imbalance of eye muscle balance. Temporomandibular joint disease, temporomandibular joint disorder syndrome and temporomandibular arthritis and excessive styloid process. It can be differentiated from trigeminal neuralgia because of its etiology and performance.

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