Althea Vol 4 No 1 full text.indd


Althea Medical Journal. 2017;4(1)

47

Clinical Characteristics of Trigeminal Neuralgia Patients at Dr. Hasan 
Sadikin General Hospital Bandung Indonesia in 2010–2012

Sri Hudaya Widihastha,1 Henny Anggraini Sadeli,2 Arifin Sunggono3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Neurology Faculty of Medicine 

Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Anatomy 
and Cell Biology Faculty of Medicine Universitas Padjadjaran

Abstract

Background: Trigeminal neuralgia is a frequently found craniofacial neuralgia. The clinical characteristics 
of trigeminal neuralgia patients at Dr. HasanSadikin General Hospital, Bandung, Indonesia has never been 
described before. This study conducted an overview of clinical characteristics of trigeminal neuralgia to 
determine the characteristic features of trigeminal neuralgia.
Methods: This was a non-experimental study using secondary data with a retrospective descriptive method. 
Data related to medical records of 76 patients with trigeminal neuralgia was collected over a period of 2010 
to 2012, treated at Dr.HasanSadikin General Hospital Bandung, Indonesia. 
Results: Mean age was 57.6 years (range 11 to 84 years), no significant difference in gender (male:females 
51.3%:48.7%). Chewing and swallowing was reported as triggering stimuli to 42 (55%) patients. Two 
patients (2.7%) had suffered pain on bilateral side of the face, 46 (60.5%) patients the right side, and 28 
patients (36.8%) on the left side. Pain on maxillary nerve division was found in 58 (76.3%) patients. Sixty 
one of the patients (80%) received Carbamazepine.
Conclusions: The peak age was between the fifth and sixth decades of life with equal representation of 
male to female incidence. Right side and the maxillary division was found to be the most frequently site of 
pain. Chewing and swallowing was reported to be the most frequent triggering stimuli and most of patients 
received Carbamazepine as therapy. [AMJ.2017;4(1):47–51]

Keywords: Clinical characteristic, neuropathic pain, trigeminal neuralgia

Correspondence: Sri Hudaya Widihastha, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang 
Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 85659966936  Email: s.widihastha@gmail.com

Introduction

Trigeminal neuralgia is a form of neuropathic 
pain disorder characterized by episodes of pain 
in the area which innervated by the trigeminal 
nerve and characterized as a spontaneous, 
recurrent, sharp, and paroxysmal pain.1 
Trigeminal neuralgia is one of craniofacial 
neuralgia which is known often to be found.1–3 
with a prevalence of 0.1–0.2 per thousand and 
an incidence ranging from about 4-5/100,000/
year up to 20/100,000/year after age 60.4 
Trigeminal neuralgia has been classified 
into Type 1 and Type 2 subtypes. Type 1 is 
characterized by lancinating, intermittent pain 
present for more than 50% of the time, while 
type 2 is characterized by a constant pain that 
is present for more than 50% of the time.5

This study conducted an overview of 
clinical characteristics of trigeminal neuralgia 

to determine the characteristic features 
of trigeminal neuralgia. The results of this 
study was expected to be useful to improve 
the knowledge and literature on trigeminal 
neuralgia, which can be used as references 
for further research. It is also expected 
that the results can provide an overview of 
the characteristics of trigeminal neuralgia, 
which can be considered for early detection 
the disease and further management of the 
patient.

Methods

This was a non-experimental study using 
secondary data with a retrospective descriptive 
method. Data related to medical records of 
76 patients with trigeminal neuralgia in the 
Outpatient Clinic of Neurology Department, 
Dr. Hasan Sadikin General Hospital, Bandung 



Althea Medical Journal. 2017;4(1)

48     AMJ March 2017

was searched and collected over a period of 
three years, from 2010 to 2012. All available 
medical records of patients with trigeminal 
neuralgia as diagnosis are used, i.e. total 
sampling method. The inclusion criterion 
was complete medical record with trigeminal 
neuralgia as diagnosis, and medical records 
with incomplete data were excluded. The 
variables analyzed were age at onset, gender, 
site of involvement, triggering stimuli, affected 
divisions of trigeminal nerve, and management 
therapy given to the patients.

Data collection approval was obtained 
from the Health Research Ethics Committee 
of the Dr Hasan Sadikin General Hospital. The 
analysis was performed by using software 

applications Microsoft Excel and the results of 
this study were then evaluated and presented 
descriptively in table.

Results

The age of patients was ranged between 11 to 
84 years old, with a mean age of 57.6 years. 
The peak incidence was in the fifth and sixth 
decades of life (Table 1).

Females comprised 51% of the patients, 
representing a ratio with males of 5.3:5, 
reflecting that female gender is more common 
than male with no significance difference 
between them.

Table 1 Clinical Characteristics of Trigeminal Neuralgia Patients

Characteristics Number of patients (n=76) Percentage (%)

Gender
Male 37 49
Female 39 51
Age (years old)
Childhood (0–14) 1 1
Adulthood (15–49) 17 23
Elderly (>49) 58 76
Triggering Stimuli
Chewing and swallowing 42 55
Talking 18 24
Washing 15 20
Tooth brushing 11 15
Wind-blowing 4 5
Shaving 3 4
Touching 3 4
Opening mouth 3 4
    Heat 1 1
Management
Carbamazepine 61 80
Amitriptyline 34 45
Tramadol 4 5
Phenytoin 3 4
Baclofen 1 1
Gabapentin 1 1
Surgical operation 1 1



Althea Medical Journal. 2017;4(1)

49Sri Hudaya Widihastha, Henny Anggraini Sadeli, Arifin Sunggono: Clinical Characteristics of Trigeminal Neuralgia Patients at Dr. Hasan Sadikin General Hospital Bandung Indonesia in 2010–2012

Chewing and swallowing was reported to be 
the most frequent triggering stimuli. All of the 
76 patients received medical treatment. Sixty-
one of the patients (80%) received different 
dosages of carbamazepine and most of cases 
received more than one medical treatment. 
There was one case of surgical operation as 
other forms of modality employed to further 
ease the pain.

Two patients had bilateral trigeminal 
nerve involvement constituting 2% of the 
series (Table 2). Of the remaining 74 cases, 46 
patients (61%) suffered pain on the right side 
of the face, and 28(37%) patients on the left 
side. This finding gave a right site and left site 
ratio of 1.7:1, confirming a predominance of 
right side facial affliction.

The maxillary division was found to be the 
most frequently involved branch. Twenty-five 
patients (33%) were reported having neuralgic 
pain only at the maxillary distribution of 
the face, fifteen patients (20%) suffered the 
condition with the additional involvement 
of the mandibular division on the same side, 
six patients (8%) suffered the condition with 
the additional involvement of the ophthalmic 
division, and twelve patients (16%) were 
reported having neuralgic pain confined solely 
at all division of trigeminal nerve distribution 
of the face. Fourteen patients (18%) were 
reported having neuralgic pain at only the 
mandibular distribution of the face and the 
least frequent divisions of trigeminal neuralgia 
is ophthalmic division (5%).

Discussions

This present study reported that the peak 
age of the disease was between the fifth and 

sixth decades of life. Similar findings was also 
reported by previous retrospective studies 
which reported that the peak age of onset 
were between the fifth and eighth decades of 
life.6-9 Loh et al.10 stated on his study that this 
concurrence supports the cardinal rule of 
subjecting patients under 40 years of age who 
complain of neuralgia-like pain in the face to 
a detailed neurological assessment to exclude 
associated diseases like multiple sclerosis. 
The causes of trigeminal neuralgia include 
mechanical suppression by blood vessels, 
arterial venous malformations surrounding, 
suppression by lesions or tumors, multiple 
sclerosis, physical damage of the trigeminal 
nerve due to surgery or infection, and other 
unknown factors. Therefore, there were 
unusual patients aged less than 40 years cases 
reported in this recent study, which needed to 
be investigated further.

Katusic et al.6 reported female 
predominance in the ratio of 5.9:3.4. Although 
other reviewers also reported that the disorder 
was appeared having a gender inclination, 
different result was seen in this present study. 
The result reported that there was more likely 
an equal representation of male to female 
incidence, with a ratio of 5.3:5. Nayyar et al.9 
reported that male predominance, was more 
likely due to smaller sample size. This finding 
may be unique to the general populations and, 
therefore, deserves further study with a larger 
sample size.

The majority of the patients in this study 
were sensitive to a multitude of triggering 
stimuli which was varied in both type and 
intensity. Most common triggering stimuli 
included chewing and swallowing (55%), 
talking (24%), washing (20%), tooth brushing 
(15%). Those triggering stimulus were also 

Table 2 Affected Divisions and Site of Involvement in Trigeminal Neuralgia Patients

Affected divisions of trigeminal nerve 
and site of involvement Bilateral

Side of face
Total

Right side Left side
Ophthalmic 0 3 1 4
Maxillary 1 13 11 25
Mandibular 0 8 6 14
Ophthalmic, Maxillary 0 4 2 6
Ophthalmic, Mandibular 0 0 0 0
Maxillary, Mandibular 1 12 2 15
Ophthalmic, Maxillary, Mandibular 0 6 6 12
Total 2 46 28 76



Althea Medical Journal. 2017;4(1)

50     AMJ March 2017

reported in the previous study.10
Neto et al.11 stated that in trigeminal 

neuralgia the right side of the face usually  
afflict more than the left, since it is known that 
the foramen rotundum and foramen ovale on 
the right is narrower. In this study, the right 
side of the face was also much more involved 
(ratio 1.7:1). The proportion of bilateral 
cases in this study (2%) has similar range of 
percentage with those of previous reports 
which were stated as less than, or equal to 3 
%.6

This study demonstrated about 58 of the 
patients (76%) in the present series reported 
affliction of the maxillary division either 
alone or in combination with the other two 
divisions. This report made the maxillary 
branch as the most frequently affected branch 
of the fifth cranial nerve. Reports from other 
studies stated the similar findings.6,8 Loh et 
al.10 reported that contradictory result, stated 
mandibular divisions was the most frequently 
affected branch. However, all support the 
usual feature of this condition in which the 
mandibular and maxillary divisions are more 
commonly involved than the ophthalmic. These 
presentations emphasized the importance of 
eliminating potential dental etiology, since the 
pain may mimic that of toothache because of 
the maxillary and mandibular site of pain and 
it is well known that dental extractions have 
been performed because of wrong diagnosis.10 

From this present study, the ophthalmic 
division involvements to the pain need to be 
investigated further, because the number 
of patients (29%) is higher than the studies 
conducted before hand. Since this present study 
was retrospective, it is needed to consider the 
limitation of retrospective study and the lack 
of further examination, for example Magnetic 
Resonance Imaging (MRI) on patients. It 
was also known that central sensitization of 
neuropathic pain can affect the distributions 
of patients’ sensation of pain, especially to the 
area of ophthalmic division, which is known as 
a very rare to be affected directly by trigeminal 
neuralgia.

Pharmacological treatment of trigeminal 
neuralgia is usually used as the first option 
and, in some patients surgical options may be 
offered.10 Carbamazepine is highly effective and 
specific for this condition.12 Carbamazepine is a 
tricyclic imipramine with mechanism of action 
related to its ability to block voltage sensitive 
sodium channels which result in stabilization 
of the hyper excitable trigeminal neural 
membranes.13 Some previous studies and its 
subsequent wide-spread use of it in trigeminal 

neuralgia case made carbamazepine as a drug 
of choice.14 Four placebo-controlled studies 
totaling 147 patients demonstrated the 
efficacy of carbamazepine.14 The treatment 
response in these trials was robust, with 
58 to 100% of patients on carbamazepine 
attaining complete or near complete pain 
control as compared to 0 to 40% of patients 
on placebo.14 which makes carbamazepine as 
the first line drug for medical management 
of the disease.12,15 Carbamazepine reduced 
both the frequency and intensity of painful 
paroxysms and was equally efficacious for 
spontaneous and trigger-evoked attacks.12 
This therapeutic response also aided in the 
diagnostic cconfirmation of the condition in 
this study.10 On this present study, it was found 
that Carbamazepine and Phenytoin can be 
given as monotheraphy.

Most of the patients in the present study 
were treated with Carbamazepine, and they 
responded favourably. Possible side effects such 
as skin rashes, leukopenia, thrombocytopenia, 
abnormal liver function, and cerebellar 
dysfunction may occur in 5 to 10% of those 
patients taking these medications.10 The long 
term effects of Carbamazepine have been 
evaluated in one study, showing either loss 
of effect or problem with tolerability in one 
half patients over 10 years. Other treatments 
were given including tricyclic antidepressant, 
Amitriptyline (45%). This antidepressant 
treatment was also given to the patients in the 
study that conducted by Loh et al.10

Some of the patients also received various 
medical treatment, such as Tramadol (5%), 
Phenytoin (4%), Gabapentin (1%), and 
Baclofen (1%). Those treatment were useful 
as an alternative in patients who need add on 
therapy beside carbamazepine or the given 
therapy is known to be ineffective.12,16 Surgical 
intervention was employed to relieve the 
intractablepain of one young-aged patient. 
However, it is not without risk of morbidity 
and mortality.10 Each surgical technique for 
treatment of trigeminal neuralgia has merits and 
limitations and microvasculardecompression 
was known to provide the highest rate of long-
term patient’ satisfaction with the lowest rate 
of pain recurrence.17

Limitation in terms of time and number of 
samples in this study, making further research 
deemed necessary. Lack of specific clinical 
or laboratory test exists for the diagnosis 
of symptomatic trigeminal neuralgia might 
be also the limitation of this study, since the 
etiological basis of classic trigeminal neuralgia 
is unknown but vascular compression of the 



Althea Medical Journal. 2017;4(1)

51

trigeminal nerve roots has emerged as the 
likely cause in most cases.19 

As a conclusion, this study demonstrated 
numerous clinical similarities of trigeminal 
neuralgia afflicting to the previous studies. 
This present study reported that the peak age 
was between the fifth and sixth decades of life 
with equal representation of male to female 
incidence. Right side and the maxillary division 
were found to be the most frequently site of 
pain. Chewing and swallowing were reported 
to be the most frequent triggering stimuli and 
most of patients received Carbamazepine as 
therapy. The sample size could be increased 
to present clearer data evidence. Follow-up 
studies would be beneficial to establish distinct 
Indonesian patterns in this neurological 
disorder for further recommendation.

References

1. Prasad S, Galetta S. Trigeminal neuralgia: 
historical notes and current concepts. 
Neurologist. 2009;15(2):87–94.

2. Krafft RM. Trigeminal neuralgia. Am Fam 
Physician 2008;77(9):1291–6.

3. Hall GC, Carroll D, Parry D, McQuay 
HJ. Epidemiology and treatment of 
neuropathic pain: the UK primary care 
perspective. Pain. 2006;122(1–2):156–62. 

4. Manzoni GC, Torelli P. Epidemiology of 
typical and atypical craniofacial neuralgias. 
Neurol Sci. 2005;26(2):65–7.

5. Eller JL, Raslan AM, Burchiel KJ. Trigeminal 
neuralgia: definition and classification. 
Neurosurg Focus. 2005;18(5):E3.

6. Katusic S, Beard CM, Bergstralh E, 
Kurland LT. Incidence and clinical features 
of trigeminal neuralgia, Rochester, 
Minnesota, 1945-1984. Ann Neurol. 
1990;27(1):89–95.

7. Jainkittivong A, Aneksuk V, Langlais RP. 
Trigeminal neuralgia: a retrospective 
study of 188 Thai cases. Gerodontology. 
2012;29(2):e611–7.

8. Siqueira SR, Teixeira MJ, Siqueira JT. Clinical 
characteristics of patients with trigeminal 
neuralgia referred to neurosurgery. Eur J 
Dent. 2009; 3(3):207–212.

9. Nayyar AS, Khan M. Trigeminal neuralgia: 
revisiting clinical characteristics in the 

Indian scenario. Jour of Med Sc & Tech. 
2012;1(2):9–17. 

10. Loh HS, Ling SY, Shanmuhasuntharam 
P, Zain R, Yeo JF, Khoo SP. Trigeminal 
neuralgia: a retrospective survey of a 
sample of patients in Singapore and 
Malaysia.Aust Dent J. 1998;43:(3):188–91.

11. Neto  HS, Camilli  JA, Marques  MJ. 
Trigeminal neuralgia is caused by maxillary 
and mandibular nerve entrapment: 
greater incidence of right-sided facial 
symptoms is due to the foramen rotundum 
and foramen ovale being narrower on the 
right side of the cranium. Med Hypotheses. 
2005;65(6):1179 – 82.

12. Gronseth G, Cruccu G, Alksne J, 
Argoff C, Brainin M, Burchiel K, et al. 
Practice parameter: the diagnostic 
evaluation and treatment of trigeminal 
neuralgia (an evidence-based review): 
report of thequality standards 
subcommittee of the American 
academy ofneurology and the European 
Federation of Neurological Societies. 
Neurology.2008;71(15):1183–90.

13. McNamara JO. Goodman & Gilman’s the 
pharmacological basis therapeutics. 12th 
ed. New York. McGraw Hill: 2001.

14. Campbell FG, Graham JG, Zilkha KJ. Clinical 
trial of Carbamazepine (Tegretol) in 
trigeminal neuralgia. J Neurol Neurosurg 
Psychiatry. 1966;29(3):265–7.

15. Jorns TP, Zakrzewska JM. Evidence-based 
approach to the medical management 
of trigeminal neuralgia. Br J Neurosurg. 
2007;21(3):253 – 61.

16. Bennetto L, Patel NK, Fuller G. Trigeminal 
neuralgia and its management. BMJ. 
2007;334(586):201–5.

17. Tatli M, Satici O, Kanpolat Y, Sindou M. 
Various surgical modalities for trigeminal 
neuralgia: literature study of respective 
long-term outcomes. Acta Neurochirurgica. 
2008;150(3):243–255.

18. Hasan S, Khan NI, Sherwani OA, Bhatt V, 
Asif S. Trigeminal Neuralgia: an overview 
of literature with emphasis medical 
management. International Research 
Journal of Pharmacy. 2012;3(11):235–8.

19. Thomas KL, Vilensky JA. The anatomy 
of vascular compression in trigeminal 
neuralgia. Clin Anat. 2014;27(1):89–93

Sri Hudaya Widihastha, Henny Anggraini Sadeli, Arifin Sunggono: Clinical Characteristics of Trigeminal 
Neuralgia Patients at Dr. Hasan Sadikin General Hospital Bandung Indonesia in 2010–2012