The Neuralgias: Diagnosis and Management

Abstract

The neuralgias are characterized by pain in the distribution of a cranial or cervical nerve. While most often brief, severe, and paroxysmal, continuous neuropathic pain may occur. The most commonly encountered entities include trigeminal, postherpetic, glossopharyngeal, and occipital neuralgia. More unusual cranial neuralgias may occur in periorbital (eg, supraorbital neuralgia) and auricular (eg, nervus intermedius neuralgia) distributions. These disorders may be mimicked by structural and inflammatory/infectious neurologic disease, along with other primary headache disorders (eg, primary stabbing headache). The approach to diagnosis and treatment of this group of headache disorders is reviewed.

This is a preview of subscription content, access via your institution.

Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Smith JH, Cutrer FM. Numbness matters: a clinical review of trigeminal neuropathy. Cephalalgia. 2011;31:1131–44.

    PubMed  Article  Google Scholar 

  2. 2.•

    Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629–808. Recent revision of the ICHD-2 2004 headache diagnostic criteria.

    Article  Google Scholar 

  3. 3.

    Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain. Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1–226.

  4. 4.

    De Simone R, Ranieri A, Bilo L, et al. Cranial neuralgias: from physiopathology to pharmacological treatment. Neurol Sci. 2008;29 Suppl 1:S69–78.

    PubMed  Article  Google Scholar 

  5. 5.

    Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain. 2001;124(Pt 12):2347–60.

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Manzoni GC, Torelli P. Epidemiology of typical and atypical craniofacial neuralgias. Neurol Sci. 2005;26 Suppl 2:s65–7.

    PubMed  Article  Google Scholar 

  7. 7.

    Katusic S, Beard CM, Bergstrahl E, et al. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol. 1990;27:89–95.

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Watson CP. Postherpetic neuralgia. Neurol Clin. 1989;7:231–48.

    CAS  PubMed  Google Scholar 

  9. 9.

    Katusic S, Williams DB, Beard CM, et al. Incidence and clinical features of glossopharyngeal neuralgia, Rochester, Minnesota, 1945-1984. Neuroepidemiology. 1991;10:266–75.

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Koopman JS, Dieleman JP, Huygen FJ, et al. Incidence of facial pain in the general population. Pain. 2009;147:122–7.

    PubMed  Article  Google Scholar 

  11. 11.

    Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008;71:1183–90.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Bahgat D, Ray DK, Raslan AM, et al. Trigeminal neuralgia in young adults. J Neurosurg. 2011;114:1306–11.

  13. 13.

    Pollack IF, Jannetta PJ, Bissonette DJ. Bilateral trigeminal neuralgia: a 14-year experience with microvascular decompression. J Neurosurg. 1988;68:559–65.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Rozen TD, Capobianco DJ, Dalessio DJ. Cranial neuralgias and other causes of facial pain. In: Silberstein SD, Lipton RB, Dodick DW, editors. Wolff's Headache and other head pain. New York: Oxford University Press; 2008. p. 633–50.

  15. 15.

    Fromm GH, Graff-Radford SB, Terrence CF, et al. Pre-trigeminal neuralgia. Neurology. 1990;40:1493–5.

  16. 16.

    Rushton JG, Macdonald HN. Trigeminal neuralgia: special considerations of nonsurgical treatment. J Am Med Assoc. 1957;165:437–40.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Zhang J, Yang M, Zhou M, et al. Non-antiepileptic drugs for trigeminal neuralgia. Cochrane Database Syst Rev. 2013;12, CD004029.

  18. 18.

    Lechin F, van der Dijs B, Lechin ME, et al. Pimozide therapy for trigeminal neuralgia. Arch Neurol. 1989;46:960–3.

  19. 19.

    Wu CJ, Lian YJ, Zheng YK, et al. Botulinum toxin type A for the treatment of trigeminal neuralgia: results from a randomized, double-blind, placebo-controlled trial. Cephalalgia. 2012;32:443–50.

    PubMed  Article  Google Scholar 

  20. 20.

    Hu Y, Guan X, Fan L, et al. Therapeutic efficacy and safety of botulinum toxin type A in trigeminal neuralgia: a systematic review. J Headache Pain. 2013;14:72.

    PubMed Central  PubMed  Article  Google Scholar 

  21. 21.

    Cheshire WP. Fosphenytoin: an intravenous option for the management of acute trigeminal neuralgia crisis. J Pain Symptom Manag. 2001;21:506–10.

    CAS  Article  Google Scholar 

  22. 22.

    Arai YC, Hatakeyama N, Nishihara M, et al. Intravenous lidocaine and magnesium for management of intractable trigeminal neuralgia: a case series of nine patients. J Anesth. 2013;27:960–2.

    PubMed  Article  Google Scholar 

  23. 23.

    Zakrzewska JM, Akram H. Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Cochrane Database Syst Rev. 2011:CD007312.

  24. 24.

    Barker FG, 2nd, Jannetta PJ, Bissonette DJ, et al. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med. 1996;334:1077–83.

  25. 25.

    Amador N, Pollock BE. Repeat posterior fossa exploration for patients with persistent or recurrent idiopathic trigeminal neuralgia. J Neurosurg. 2008;108:916–20.

    PubMed  Article  Google Scholar 

  26. 26.

    Gorgulho AA, De Salles AA. Impact of radiosurgery on the surgical treatment of trigeminal neuralgia. Surg Neurol. 2006;66:350–6.

    PubMed  Article  Google Scholar 

  27. 27.

    Kondziolka D, Zorro O, Lobato-Polo J, et al. Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg. 2010;112:758–65.

  28. 28.

    Revuelta-Gutierrez R, Martinez-Anda JJ, Coll JB, et al. Efficacy and safety of root compression of trigeminal nerve for trigeminal neuralgia without evidence of vascular compression. World Neurosurg. 2013;80:385–9.

  29. 29.

    Broggi G, Ferroli P, Franzini A, et al. Operative findings and outcomes of microvascular decompression for trigeminal neuralgia in 35 patients affected by multiple sclerosis. Neurosurgery. 2004;55:830–8. discussion 838–9.

    PubMed  Article  Google Scholar 

  30. 30.

    Ariai MS, Mallory GW, Pollock BE. Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis. World Neurosurg. 2014;81(3-4):599–603

  31. 31.

    Resnick DK, Janneta PJ, Lunsford LD, et al. Microvascular decompression for trigeminal neuralgia in patients with multiple sclerosis. Surg Neurol. 1996;46:358–61. discussion 361–2.

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Zorro O, Lobato-Polo J, Kano H, et al. Gamma knife radiosurgery for multiple sclerosis-related trigeminal neuralgia. Neurology. 2009;73:1149–54.

  33. 33.

    Yawn BP, Gilden D. The global epidemiology of herpes zoster. Neurology. 2013;81:928–30.

    PubMed Central  PubMed  Article  Google Scholar 

  34. 34.

    Ragozzino MW, Melton LJ, 3rd, Kurland LT, et al. Population-based study of herpes zoster and its sequelae. Medicine. 1982;61:310–6.

  35. 35.

    Birlea M, Nagel MA, Khmeleva N, et al. Varicella-zoster virus trigeminal ganglioneuritis without rash. Neurology. 2014;82:90–2.

    PubMed  Article  Google Scholar 

  36. 36.

    Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352:2271–84.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Schmader KE, Levin MJ, Gnann JW, Jr et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50–59 years. Clin Infect Dis. 2012;54:922–8.

  38. 38.

    Chen N, Li Q, Yang J, et al. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2014;2, CD006866.

    PubMed  Google Scholar 

  39. 39.

    Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63:959–65.

  40. 40.

    Kochar DK, Garg P, Bumb RA, et al. Divalproex sodium in the management of postherpetic neuralgia: a randomized double-blind placebo-controlled study. QJM. 2005;98:29–34.

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Quan D, Hammack BN, Kittelson J, et al. Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Arch Neurol. 2006;63:940–2.

    PubMed  Article  Google Scholar 

  42. 42.

    Blumenfeld A, Nikolskaya G. Glossopharyngeal neuralgia. Curr Pain Headache Rep. 2013;17:343.

    PubMed  Article  Google Scholar 

  43. 43.

    Minagar A, Sheremata WA. Glossopharyngeal neuralgia and MS. Neurology. 2000;54:1368–70.

    CAS  PubMed  Article  Google Scholar 

  44. 44.

    Bruyn GW. Glossopharyngeal neuralgia. Cephalalgia. 1983;3:143–57.

    CAS  PubMed  Article  Google Scholar 

  45. 45.

    Rushton JG, Stevens JC, Miller RH. Glossopharyngeal (vagoglossopharyngeal) neuralgia: a study of 217 cases. Arch Neurol. 1981;38:201–5.

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Reddy K, Hobson DE, Gomori A, et al. Painless glossopharyngeal "neuralgia" with syncope: a case report and literature review. Neurosurgery. 1987;21:916–9.

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    Mason III JO, Katz B, Greene HH. Severe ocular pain secondary to occipital neuralgia following vitrectomy surgery. Retina. 2004;24:458–9.

    PubMed  Article  Google Scholar 

  48. 48.

    Hammond SR, Danta G. Occipital neuralgia. Clin Exp Neurol. 1978;15:258–70.

    CAS  PubMed  Google Scholar 

  49. 49.

    Lord SM, Barnsley L, Wallis BJ, et al. Third occipital nerve headache: a prevalence study. J Neurol Neurosurg Psychiatry. 1994;57:1187–90.

  50. 50.

    Vanelderen P, Lataster A, Levy R, et al. Occipital neuralgia. Pain Pract. 2010;10:137–44.

    PubMed  Article  Google Scholar 

  51. 51.

    Boes CJ. C2 myelitis presenting with neuralgiform occipital pain. Neurology. 2005;64:1093–4.

    PubMed  Article  Google Scholar 

  52. 52.

    Kemp III WJ, Tubbs RS, Cohen-Gadol AA. The innervation of the scalp: a comprehensive review including anatomy, pathology, and neurosurgical correlates. Surg Neurol Int. 2011;2:178.

    PubMed Central  PubMed  Article  Google Scholar 

  53. 53.

    Saunders RL, Weider D. Tympanic membrane sensation. Brain. 1985;108(Pt 2):387–404.

    PubMed  Article  Google Scholar 

  54. 54.

    Caminero AB, Pareja JA. Supraorbital neuralgia: a clinical study. Cephalalgia. 2001;21:216–23.

    CAS  PubMed  Article  Google Scholar 

  55. 55.

    Mulero P, Guerrero AL, Pedraza M, et al. Non-traumatic supraorbital neuralgia: a clinical study of 13 cases. Cephalalgia. 2012;32:1150–3.

    PubMed  Article  Google Scholar 

  56. 56.

    Sjaastad O, Stolt-Nielsen A, Pareja JA, et al. Supraorbital neuralgia. On the clinical manifestations and a possible therapeutic approach. Headache. 1999;39:204–12.

  57. 57.

    Taylor RW, Samuels HS. Neuralgia involving the infraorbital nerve: report of case. J Oral Surg. 1952;10:248–50.

    CAS  PubMed  Google Scholar 

  58. 58.

    Lopez Mesonero L, Pedraza Hueso MI, Herrero Velazquez S, et al. Infraorbital neuralgia: a diagnostic possibility in patients with zygomatic arch pain. Neurologia. 2013;33:1198–202.

  59. 59.

    Pareja JA, Cuadrado ML. Lacrimal neuralgia: so far, a missing cranial neuralgia. Cephalalgia. 2013;33:1198–202.

    PubMed  Article  Google Scholar 

  60. 60.

    Cuadrado ML, Aledo-Serrano A, Jorquera M, et al. A new lacrimal neuralgia, a new nerve blockade procedure. Cephalalgia. 2014;13:812–4.

  61. 61.

    Carroll RP. Blindness following lacrimal nerve block. Ophthalmic Surg. 1982;13:812–4.

    CAS  PubMed  Google Scholar 

  62. 62.

    Speciali JG, Goncalves DA. Auriculotemporal neuralgia. Curr Pain Headache Rep. 2005;9:277–80.

    PubMed  Article  Google Scholar 

  63. 63.

    Pomprasit M, Chintrakarn C. Treatment of Frey's syndrome with botulinum toxin. J Med Assoc Thai. 2007;90:2397–402.

    PubMed  Google Scholar 

  64. 64.

    Rustemeyer J, Eufinger H, Bremerich A. The incidence of Frey's syndrome. J Craniomaxillofac Surg. 2008;36:34–7.

    PubMed  Article  Google Scholar 

  65. 65.

    Ansari H, Robertson CE, Jane JI, et al. Auriculotemporal neuralgia secondary to TMJ synovial cyst: a rare presentation of a rare entity. Headache. 2013;53:1662–5.

    PubMed  Article  Google Scholar 

  66. 66.

    Smith JH, Robertson CE, Garza I, et al. Triggerless neuralgic otalgia: a case series and systematic literature review. Cephalalgia. 2013;33:914–23.

    PubMed  Article  Google Scholar 

  67. 67.

    Pareja JA, Ruiz J, de Isla C, et al. Idiopathic stabbing headache (jabs and jolts syndrome). Cephalalgia. 1996;16:93–6.

  68. 68.

    Liang X, Ying G, Huang Q, et al. Characteristics of primary stabbing headache in a tertiary neurological clinic in China. Pain Med. 2014;24:993–6.

  69. 69.

    Franca Jr MC, Costa AL, Maciel Jr JA. Gabapentin-responsive idiopathic stabbing headache. Cephalalgia. 2004;24:993–6.

    PubMed  Article  Google Scholar 

  70. 70.

    Jacome DE. Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia. 2001;21:617–8.

    CAS  PubMed  Article  Google Scholar 

  71. 71.

    Rozen TD. Melatonin as treatment for idiopathic stabbing headache. Neurology. 2003;61:865–6.

    PubMed  Article  Google Scholar 

  72. 72.

    Fusco C, Pisani F, Faienza C. Idiopathic stabbing headache: clinical characteristics of children and adolescents. Brain Dev. 2003;25:237–40.

    PubMed  Article  Google Scholar 

  73. 73.

    Pareja JA, Cuadrado ML, Caminero AB, et al. Duration of attacks of first division trigeminal neuralgia. Cephalalgia. 2005;25:305–8.

    CAS  PubMed  Article  Google Scholar 

  74. 74.

    Pareja JA, Baron M, Gili P, et al. Objective assessment of autonomic signs during triggered first division trigeminal neuralgia. Cephalalgia. 2002;22:251–5.

    CAS  PubMed  Article  Google Scholar 

  75. 75.

    Lain AH, Caminero AB, Pareja JA. SUNCT syndrome: absence of refractory periods and modulation of attack duration by lengthening of the trigger stimuli. Cephalalgia. 2000;20:671–3.

    CAS  PubMed  Article  Google Scholar 

  76. 76.

    Paliwal VK, Singh P, Kumar A, et al. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) with preserved refractory period: report of three cases. J Headache Pain. 2012;13:167–9.

    PubMed Central  PubMed  Article  Google Scholar 

  77. 77.

    Cohen AS, Matharu MS, Goadsby PJ. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)—a prospective clinical study of SUNCT and SUNA. Brain. 2006;129(Pt 10):2746–60.

    PubMed  Article  Google Scholar 

  78. 78.

    Benoliel R, Sharav Y. Trigeminal neuralgia with lacrimation or SUNCT syndrome? Cephalalgia. 1998;18:85–90.

    CAS  PubMed  Article  Google Scholar 

  79. 79.

    Rinaldi F, Rao R, Venturelli E, et al. Where SUNCT contacts TN: a case report. Headache. 2013;53:1492–5.

    PubMed  Google Scholar 

  80. 80.

    Pareja JA, Kruszewski P, Sjaastad O. SUNCT syndrome: trials of drugs and anesthetic blockades. Headache. 1995;35:138–42.

    CAS  PubMed  Article  Google Scholar 

  81. 81.

    Pareja JA, Alvarez M. The usual treatment of trigeminal autonomic cephalalgias. Headache. 2013;53:1401–14.

    PubMed  Google Scholar 

  82. 82.

    Sebastian S, Schweitzer D, Tan L, et al. Role of trigeminal microvascular decompression in the treatment of SUNCT and SUNA. Curr Pain Headache Rep. 2013;17:332.

    PubMed  Article  Google Scholar 

  83. 83.

    Lambru G, Shanahan P, Watkins L, et al. Occipital nerve stimulation in the treatment of medically intractable SUNCT and SUNA. Pain Physician. 2014;17:29–41.

    PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Paul M. Gadient and Jonathan H. Smith declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Jonathan H. Smith.

Additional information

This article is part of the Topical Collection on Headache

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gadient, P.M., Smith, J.H. The Neuralgias: Diagnosis and Management. Curr Neurol Neurosci Rep 14, 459 (2014). https://doi.org/10.1007/s11910-014-0459-3

Download citation

Keywords

  • Neuralgia
  • Cranial neuralgia
  • Trigeminal neuralgia
  • Occipital neuralgia
  • Postherpetic neuralgia
  • Glossopharyngeal neuralgia
  • Nervus intermedius neuralgia
  • Auriculotemporal neuralgia