Collaborative Care in the Treatment of Trigeminal Neuralgia

Trigeminal neuralgia (TN) isn’t a particularly common form of pain, but for patients who suffer from it, the pain is often brief but is very severe. Because of its rarity, TN is often mistreated or under-treated. Even when treatment is appropriately delivered, there can be troublesome side effects and complications. Proper diagnosis and treatment typically involves coordination of care among neurologists, anaesthesiologists, dentists, neurosurgeons, and neuroradiologists.

A recent article in the Journal of Headache and Pain examined a collaborative referral and treatment strategy that could be of significant benefit for TN patients. The article looked at the effectiveness and strategy behind an accelerated management program at the Danish Headache Center (DHC) for TN.

The primary goals of the strategy were to establish a collaboration protocol and a focus on ensuring correct diagnosis; excludesecondary causes of pain; optimize medical treatment and educate patients on how to use medications properly to manage pain and decrease side effects; and determine the need for neurosurgical intervention when necessary.

The authors started with an accelerated work-up and treatment program with a seamless patient path based on a formal collaboration among the DHC, the Department of Radiology, and the Department of Neurosurgery. The aim was to see TN patients within 2 to 6 weeks after referral, a significant acceleration in a public Danish healthcare system in which patients can wait up to 2 years for specialist treatment with a headache referral.

The authors note, “Early diagnosis will save some TN patients from unnecessary dental treatments and years of suboptimal medical treatment. Median waiting time for the first out-patient visit was 42 and 37 days for subsequent MRI, which we consider acceptable in a public health care system. It is our clinical experience that the waiting time for first out-patient visit has been reduced significantly since implementation.”

The streamlined approach shortened wait times and increased the quality of diagnosis via MRI. From May 2012 to April 2014, 130 patients entered the accelerated program. Ninety-four percent of the patients had a MRI performed according to the special protocol after a mean of 37 days.

Within 2 years follow-up, 35% of the patients were referred to neurosurgery after a median time of 65 days. Patients were followed for at least 2 years in order to optimize medical treatment and the need for referral to neurosurgical treatment was continuously evaluated. At each follow-up visit, the treating neurologist performed a semi-structured interview, recording whether the patient was in remission, type and dose of medical treatment and its effectiveness and side effects.

“Early high quality MRI ensured correct diagnosis and that the neurosurgeons had a standardized basis before decision-making on impending surgery,” the study authors noted. “The program ensured that referral of the subgroup of patients in need for surgery was standardized, ensured continuous evaluation of the need for adjustments in pharmacological management and formed the basis for scientific research.”

The study also looked at factors including misdiagnosis, use of combination therapy, and referrals for neurological procedure. The study authors hope the analysis will create scientific awareness of TN management and stimulate discussions about how TN ideally should be handled in clinical practice.