Trigeminal neuralgia - Pathophysiology and treatment

Trigeminal neuralgia is a very peculiar disease. The pain, also known as "t ic douloureux", is paroxystic and very severe. It can be triggered by a lig ht cutaneous stimulus on a very localized spot on the face (thr so-called " trigger zone"). The patient can sometimes benefit from long remissions with out any treatment. With the exception of multiple sclerosis and sf uncommon cases of posterior fossa tumours or other lesions impinging on the trigemi nal nerve, ganglion or root, trigeminal neuralgia is considered as "idiopat hic". Some benign abnormality had for long been suspected. The current opin ion is now in favour of a "neurovascular conflict" : an artery, most often a loop of the superior or antero-inferior cerebellar. artery, has an offend ing contact with the trigeminal nerve root, which results in localized demy elination and ectopic triggering of neuronal discharges. This hypothesis is in agreement with the relief provided by antiepileptic drugs and is suppor ted by recent neuroimaging data. Therapeutic options are reviewed: very efficient drugs are available but fa il to provide a significant relief and/or have important side effects in ma ny cases. Surgical alternatives are available, for which guidelines are pro posed