00:01
Our topic now brings us to
chronic daily headache.
00:04
Most often evolve out
of tension type though.
00:07
Almost universally associated
with analgesic abuse.
00:12
Pain is generally reported as severe.
00:14
Our patients can carry out daily
activities, but they’re not very happy.
00:18
First, the treatment is
cessation of analgesic.
00:21
Tricyclics for underlying migraine
or tension type headache.
00:26
Topic here brings us to an important
trigeminal neuralgia issue.
00:31
It comes under your subacute
or chronic headache.
00:34
Pain usually described as
being electric, shooting.
00:39
Neuralgia of your fifth
cranial nerve, trigeminal.
00:42
Most often, the mandibular
or maxillary division.
00:45
Think about where you are, please.
00:46
Mandibular or maxillary, okay?
Seen in middle age
and later life.
00:54
How’s it triggered possibly?
Non-noxious sensory stimuli to affected
face, ipsilateral mucosa, or even teeth.
01:03
Exacerbating, remitting course over years.
01:06
Now, it keeps coming,
keeps coming back.
01:09
Multiple attacks occur during
any, any exacerbation.
01:13
Spontaneous remission
occurs at any time.
01:16
This is a nerve,
but then the remission could actually
last for months or even years.
01:21
The patient feels as though
that the drug, actually --
the drug if they were
taking anything,
they might feel as though that the drug
was effective, but in all reality,
what happened?
They went into remission.
01:32
Suicide risk is high
during exacerbation.
01:36
Remember, we talked about cluster
headache in which that patient is --
that male's running around
screaming for medication.
01:42
And when there’s such pain that’s
taking place during such exacerbation,
you need to make sure
that you rule out
or you properly manage this
patient for suicidal ideation.
01:52
May be seen early in multiple
sclerosis, possibly.
01:56
It kind of behaves exactly
like this, doesn’t it?
Remitting, remission,
remitting, remission.
02:01
Divisions you’re paying attention to:
mandibular, maxillary, most commonly.
02:08
Management: Carbamazepine.
02:10
In other words, the antiepileptic.
02:12
First line therapy,
70% to 80% response
rate, actually.
02:17
Carbamazepine, antiepileptic.
02:19
Baclofen can be combined with
carbamazepine.
02:23
Baclofen, carbamazepine.
02:26
They both have the C
and B letters in them.
02:28
Surgical intervention
could be a possibility.
02:31
Decompression of the trigeminal nerve
or perhaps, what’s known
as glycerol injection.
02:36
Your focus should be on carbamazepine,
please, and maybe perhaps, baclofen.
02:40
In addition to carbamazepine, oxcarbazepine can also be used, which has better tolerability and decreased risk of drug interactions.
02:48
For patients who are intolerant of or have contraindications to these medications,
the management of trigeminal neuralgia may include other anticonvulsants such as lamotrigine, gabapentin, or topiramate.
02:59
Other alternatives are the muscle relaxants baclofen or tizanidine.
03:03
Injections with botulinum toxin A may also be effective.
03:06
Subcutaneous sumatriptan, IV lidocaine or phenytoin may provide analgesia while other medications are being titrated.
03:14
Topical lidocaine may also be of benefit to patient.