Neuralgia Doctor of Pharmacy (Pharm.D) 4th Year 2024 (2023-2024) Previous Year's Question Papers/Notes Download - HK Technical PGIMS

It is about small notes of Neuralgia.!!

1INTRODUCTION
Neuralgia is a stabbing, burning and often sever pain that occurs alongadamaged nerve, it may be anywhere in the body, but is the most commoninface and neck. The damage may be caused by several things, includes;
̌ Aging
̌ Diseases such as diabetes or multiple sclerosis
̌ An infection, such as shingles
̌ Pressure on nerves
̌ Less common causes in chemical irritation, trauma,chronic kidneydisease etc,.... TYPESOFNEURALGIA
There are several types of neuralgias are classified, some of themare ;
̌ Postherpetic neuralgia
̌Trigeminal neuralgia
̌ Glossopharyngeal neuralgia
̌ Occipital neuralgia
̌ Peripheral neuralgia
̌ Intercostal neuralgia
POSTHERPETICNEURALGIA
 Postherpetic neuralgia is the most common of shingles.  The condition affects nerve fibers and skin, causing burning pain that last
long after the rash and blisters of shingles diappear.
NEURALGIAS
2 The Chickenpox(Herpes
Zosters) virus causes
shingles.  The risk of postherpetic
neuralgia increases with
age, primarily affecting
people older than 60.  There no cure, but treatments can ease symptoms, for most people,
postherpetic neuralgia improves over time. SYMPTOMS :
The signs and symptoms of postherpetic neuralgia are most commonly inabandaround your trunk, usually on one side of your body. Signs and symptoms might include:
 Itching and numbness (itchy feeling or numbness)
 Sensitivity to light touch
 The associated pain has been described as burning, sharp and jabbing, ordeep and aching, etc,. RISKFACTORS :
When you have shingles, you might be at greater risk of developing
postherpetic neuralgia as a result of :
 Advance aging
 Severity of shingles that leads to severe rash and sever pain Other illness like chronic disease, such as diabetes
COMPLICATIONS :
Depending upon how long postherpetic neualgia last long and howpainful it is,
people with the condition can develop other symptoms that are commonwithchronic pain such as :
3 Depression
 Fatigue
 Difficulty slepping
 Lack of appetite
 Difficulty concentrating
Diagnosis :
 There is no specific test
 Anti - body measurement
 Viral culture test
PREVENTION and TREATMENT:
 The Center for Disease Control and Prevention (CDC) recommends that
adults 50 and older gets a Shingrix vaccine to prevent shingles, evenif
they’ve had shingles or the older vaccine Zostavax.  Shingrix is given in two doses, two to six months apart. Children : Vaccination
Adults : Vaccination
Herpes Zoster : Early antiviral therapy + Early treatment of neuropathicpain(eg., Amitriptyline/gabapentin)
Postherpetic neuralgia
 The CDC says two doses of Shingrix is more than 90% effective in preventingshingles and postherpetic neuralgia.
Antidepressants (eg. Amitriptyline)
Anticonvulsants
(Gabapentin, Pregabalin)
Topicals (Lidocaine,
Capsaicin)
Opioids (Tramadol,
Oxycodine, Morphine)
4 Shingrix is prefered over Zostavax.  The effectiveness may be sustained for a longer period of time thanZostavax.  Zostavax may still be used sometimes for healthy adults age 60 andolder
who aren’t allergic to Zostavax and who don’t take immune-suppressingmedications. TRIGEMINALNEURALGIA:
 Trigeminal neuralgia is a facial pain syndrome in the distribution of ≥1divisions of the trigeminal nerve.  Diagnosis is clinical, with a history of paroxysms of sharp, stabbing, intensepain lasting up to 2 minutes.  First-line therapy is medical, to which the majority of patients are partiallyresponsive.  Surgical/ablative therapies are reserved
for refractory cases.  Ablative therapies can cause facial
sensory loss and are associated with a
high recurrence rate; however, they are
relatively non-invasive and carry minimal
risk of severe morbidity/mortality.  Microvascular decompression has few long-term sequelae and
well-established efficacy but has a potential risk of major morbidity.  More research on neurostimulation is needed to define its role in thetreatment of trigeminal pain. Definition
 Trigeminal neuralgia (TN) is a facial pain syndrome in the distributionof ≥1divisions of the trigeminal nerve. It is characterised by some combinationofparoxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or aconstant component of facial pain, without associated neurological deficit.
5 The pain can be precipitated by trigger areas or factors, and repeat attacksare typically stereotyped in the individual. TRIGEMINALNERVE:
 The trigeminal nerve is one set of the cranial nerves in the head. It is thenerve responsible for providing sensation to the face. One trigeminal nerveruns to the right side of the head, while the other runs to the left.Eachof
these nerves has three distinct branches.  “Trigeminal” derives from the Latin word “tria” which means three and“geminus” which means twin. After the trigeminal nerve the brainandtravels inside the skull, it divides into three smaller branches, controllingsensations throughout the faces :
o Ophthalmic Nerve (V1) : The first branch controls sensation in a person’seye, upper eyelid and forehead. o Maxillary Nerve (V2) : The second
branch controls sensation in the lower
eyelid, cheek, Nostrils, Upper lip and
Upper gum. o Mandibular Nerve (V3) : The third
branch controls sensation in the jaw,
lower lip, lower gum and some of the
muscles used for chewing. CLASSIFICATION:
Trigeminal neuralgia is classified as classical, secondary or Idopathic, dependingonthe underlying causes.(Based up on the cause)
 Classical Trigeminal Neuralgia (75% of cases) is caused by intercranial
vascular compression of the trigeminal nerve root.  Secondary Trigeminal Neuralgia (15% of cases) is caused by another
pathological process, eg. Multiple sclerosis or tumour.
6 Idopathic Trigeminal Neuralgia (10% of cases) is diagnosed when nolessionor disease that could cause trigeminal is found. SYMPTOMS :
The symptoms of Trigeminal neuralgia are undefined but it is associated painbysymptoms to be triggered. Some of the attacks of Trigeminal neuralgia may be triggered by the following:
 Touching the skin lightly
 Washing
 Shaving
 Brushing teeth
 Blowing the nose....etc,. The symptoms of several pain disorders are similar to those of trigeminal neuralgia. The most common mimicker of TN is triggered neuropathic pain(TNP). TNPresultsfrom an injury or damage to the trigeminal nerve. TNP pain is generally descripedas being constant, dull and burning. Attacks of sharp pain can also occur,
commonly triggered by touch. Additional mimickers include :
 Temporal tendinitis
 Ernest syndrome (Injury of the stylomandibular ligment )
 Occipital Neuralgia
 Cluster Headaches/ Migraines
Diagnosis :
 TN can be very difficult to diagnose, because there are no specific diagnostictest and symptoms are very similar to other facial pain disorders.  Therefore, it is important to seek, medical care when feeling unusual, sharppain around the eyes, lips,nose, jaw, forehead and scalp, especially if youhave not had dental or other facial surgery recently.  Magnetic Resonance Imaging (MRI) can detect if a tumor or MS is affectingthe trigeminal nerve.
7 Physicians base their diagnosis on type pain (Sudden, Quick and Shocklike),
the location of the pain and things that trigger the pain.  Physical and neurological examinations may also be done in whichthedoctor will touch and examine parts of your face to better understandwhere the pain is located. TREATMENT:
PHARMACOLOGYANDNON-PHARMACOLOGYTREATMENT:
There are several effective ways to alleviate the pain, including a variety of
medications. Medications generally started at low doses and increased graduallybased on the patient’s response to the drug.  CARBAMAZEPINE, an Anti- convulsant drug, is the most common medicationthat doctors use to treat TN. In early stages of the disease, carbamazepinecontrols pain for most people. Side effects are dizzines, double vision,
drowsiness and nausea etc.,.  GABAPENTIN, an Anticounsulvant drug, which most commonly usedtotreatepilepsy or migraines can also treat TN. Side effectys are dizziness or
drowsiness..  Oxcarbazepine, a newer medication, has been used more recently as thefirst line of the treatment. It’s acts as like a carbazepine.  Other Medictaions : Baclofen, Amitriptyline, Nortriptyline, Pregabalin,
Phenytoin, Valporic acid etc,.,.  Some times Surgical treatment also prefferd, if not better with medicationi.e., divided into two categories :
o Open Cranial Surgery : patients found to have pressure on the trigeminal
nerve from a nearby blood vessel, which can be diagnosed with imagingof
the brain, such as a special MRI. o Lesioning Surgery : It produces include interventions that injure thetrigeminal nerve on purpose, in order to prevent the nerve fromdeliveringpain to the face.
8INTERCOSTALNEURALGIA:
Intercostal neuralgia affects the nerves that sit just below the ribs are calledastheintercostal muscles.Sevreal potential factors may contribute to intercostal
neuralgia, such as:
 Injuries or surgical procedures that involve the chest
 Pressure on the nerves
 Shingles or other viral infections
CAUSESANDSYMPTOMS :
 Causes a sharp, burning pain that affects the
chest wall, upper abdomen, and upper back. Certain Physical movements, such as
breathing, coughing, or laughing, can worsen
the pain. Additional symptoms may include:
 Tightness or pressure that wraps around the chest
 Tingling or numbness in the upper chest or upper back
 Muscule twitching
 Loss of appetite...etc,. GLOSSOPHARYNGEALNEURALGIA:
Glossopharyngeal neuralgia is rare condition in which there are repeatedepisodesof severe pain in the tongue, throat, ear and tonsils. This can last froma fewseconds to a few minutes. Causes :
Glossopharyngeal neuralgia is believed to br caused by irritation of the 9thcranial
nerve called as the glossopharyngeal nerve. In most cases, the source of irritationisnever found. Possible causes for this type of nerve pain are:
9 Blood vessels pressing on the glassopharyngeal nerve.  Growths at the base of the skull pressing on the glossopharyngeal nerve.  Tumors or infections of the throat and mouth pressing on the
glossopharyngeal nerve. SYMPTOMS:
The pain usually occurs on one side and may be jabbing. In rare cases, bothsidesare involved. Symptoms include severe pain in areas connected to the 9thcranial
nerve:
 Back of the nose and throat (Nasopharynx)
 Back to the tongue
 Ear
 Throat
 Tonsil area
 Voice box (Larynx)
The pain occurs in episodes and may be severe. The episodes can occur manytimeseach day and awaken the person from sleep. It can sometimes be triggeredby:
 Chewing
 Coughing
 Laughing
 Speaking.  Swallowing
 Yawning
 Sneezing
 Cold beverages
 Touching ( a blunt objects to the tonsil of the affected side)
10Diagnosis :
Tests will be done to idetify problems, such as tumors, at the base of the skull. Tests may incude :
 Blood test to rule out any infection or tumors
 CT scan of the head
 MRI of the head
 X-Rays of the head or neck
To find out whether a blood vessel is pressing on the nerve, pictures of thebrainarteries may be taken using:
 Magnetic Resonance Angiography (MRA)
 CT angiography
 X-rays of the arteries with a dye (conventional angiography)
TREATMENT:
 The goal of the treatment is to control
pain.  The most effective drugs are anti-seizure
medicines such as Carbamazepine. Antidepressent may help certain people.  In severe cases, when pain is difficult to
treat, surgery to take pressure off the
glossopharyngeal nerve may be needed. This is called Microvascular
Decompression.  The nerve can also be cut (Rhizotomy). Both surgeries are effective. If acause of the neuralgia is found, treatment should control the underlyingproblem.