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最新指南——三叉神经痛的诊断和鉴别诊断

已有 2410 次阅读 2017-3-23 07:25 |个人分类:神经科学临床和基础|系统分类:观点评述

最新指南——三叉神经痛的诊断和鉴别诊断

三叉神经神痛诊断标准：
The third edition of the International Classification of Headache Disorders (ICHD-3) defines the diagnosis of classical trigeminal neuralgia (code 13.1.1) with the following criteria:
A. at least three attacks of unilateral facial pain fulfilling criteria B and C;
B. occurring in one or more divisions of the trigeminal nerve,with no radiation beyond the trigeminal distribution;
C. pain has at least three of the following four characteristics:
1. recurring in paroxysmal attacks lasting from a fraction
of a second to 2 min,
2. severe intensity,
3. electric shock-like shooting, stabbing or sharp in quality,
4. precipitated by innocuous stimuli to the affected side of the face;
D. no clinically evident neurological deficit;
E. not better accounted for by another ICHD-3 diagnosis.

2.2.1.2.1. The diagnosis of CTN is based on ICHD-3 criteria.-The ICHD-3 distinguishes two subtypes of CTN: Classical trigeminal neuralgia: purely paroxysmal (code 13.1.1.1); and Classical trigeminal neuralgia with concomitant persistent facial pain (code 13.1.1.2) that was long considered to be an “atypical trigeminal neuralgia. These two subtypes are defined by the International Headache Society (IHS) by the following criteria.
2.2.1.2.1.1 Classical trigeminal neuralgia: purely paroxysmal (code 13.1.1.1).
Criteria of classical trigeminal neuralgia purely paroxysmal are:
A. recurrent attacks of unilateral facial pain fulfilling criteria for 13.1.1 Classical trigeminal neuralgia;
B. no persistent facial pain between attacks;
C. not better accounted for by another ICHD-3 diagnosis.
2.2.1.2.1.2 Classical trigeminal neuralgia with concomitant persistent facial pain.
Criteria of classical trigeminal neuralgia with concomitant persistent facial pain are:
A. recurrent attacks of unilateral facial pain fulfilling criteria for 13.1.1 Classical trigeminal neuralgia;
B. persistent facial pain of moderate intensity in the affected area;
C. not better accounted for by another ICDH-3 diagnosis.

2. 鉴别诊断：
2.3.1. Painful trigeminal neuropathy
Red flags suggesting PTN:
persistent sensory disorders;
deafness or auditory disorders;
poor response to carbamazepine;
skin lesions or lesion affecting the oral cavity with possible extension to the nervous system;
isolated involvement of the ophthalmic branch of the trigeminal nerve, uni- or bilaterally;
age at onset under 40 years;
optic neuritis;
personal history of MS.

2.3.2. Non-trigeminal neuralgias and Raeder’s syndrome
2.3.2.1. Glossopharyngeal neuralgia.
Diagnostic criteria of glossopharyngeal neuralgia (ICHD-
3, 13.2):
A. at least three attacks of unilateral pain fulfilling criteria B and C;
B. pain is located in the posterior part of the tongue,tonsillar fossa, pharynx, beneath the angle of the lower jaw and/or in the ear;
C. pain has at least three of the following four characteristics:
1. recurring in paroxysmal attacks lasting from a few seconds to 2 min,
2. severe intensity,
3. shooting, stabbing or sharp in quality,
4. precipitated by swallowing, coughing, talking,or yawning;
D. no clinically evident neurological deficit;
E. not better accounted for by another ICHD-3 diagnosis.
2.3.2.2. Nervus intermedius (facial nerve) neuralgia.
Diagnostic criteria of nevus intermedius neuralgia (ICHD-
3, 13.3.1):
A. at least three attacks of unilateral pain fulfilling criteria B and C;
B. pain is located in the auditory canal, sometimes radiating to the parieto-occipital region;
C. pain has at least three of the following four characteristics:
1. recurring in paroxysmal attacks lasting from a few seconds to minutes,
2. severe intensity,
3. shooting, stabbing or sharp in quality,
4. precipitated by stimulation of a trigger area in the posterior wall of the auditory canal and/or periauricular region;
D. no clinically evident neurological deficit;
E. not better accounted for by another ICHD-3 diagnosis.

2.3.2.3. Paratrigeminal oculosympathetic (Raeder’s) syndrome
The diagnostic criteria are as follows:
A. constant, unilateral headache fulfilling criterion C;
B. imaging evidence of underlying disease of either the middle cranial fossa or of the ipsilateral carotid artery;
C. evidence of causation demonstrated by both of the following:
1. headache has developed in temporal relation to the onset of the underlying disorder,
2. headache has either or both of the following features:
a) localized to the distribution of the ophthalmic division of the trigeminal nerve, with or without spread to the maxillary division;
b) aggravated by eye movement;
D. ipsilateral Horner’s syndrome;
E. not better accounted for by another ICHD-3 diagnosis.
2.3.3. Primary headaches
2.3.3.1. SUNT and SUNA.
2.3.3.2. Cluster headache.
2.3.3.3. Stabbing headache.
2.3.3.4. Epicrania fugax.
The diagnostic criteria proposed by the ICHD-3 are:
A. recurrent stabbing head pain attacks lasting 1–10 sec,
fulfilling criterion B;
B. the pain is felt to move across the surface of one hemicranium in a linear or zig-zag trajectory, commencing and terminating in the territories of different nerves;
C. not better accounted for by another ICHD-3 diagnosis.