13.1.1.2.1 Trigeminal neuralgia attributed to multiple sclerosis

Identification: Female patient, 32 years old, with a diagnosis of relapsing-remitting multiple sclerosis for 5 years, presents with paroxysmal facial pain for 3 months.

History of Present Illness:
Pain:

Location: Right V1 (ophthalmic division)

Characteristic:

Stabbing paroxysms (1-30 seconds)

Intensity: 9-10/10

Frequency: 10-50 episodes/day

Triggers:

Touching the eyebrow (trigger area)

Extreme eye movements

Associated symptoms:

Interictal paresthesias in V1

History of optic neuritis and paraparesis (2 years ago)

Course:

No completely asymptomatic periods

Gradual progression of hypoesthesia

Physical/Neurological Examination:
Trigeminal assessment:

Hypoesthesia to pinprick in right V1

Ipsilateral corneal reflex abolished

Trigger area: 5mm² on the right eyebrow

MS signs:

Positive Lhermitte's sign

Mild dysdiadochokinesia

Hyperreflexia in lower limbs

Complementary Exams:
3T MRI:

Demyelinating plaque in the pontine portion of the right trigeminal nerve

5 periventricular lesions (McDonald criteria)

CSF:

Positive oligoclonal IgG bands

Increased IgG index

Evoked Potentials:

Increased latency of P100 (visual) and N13 (somatosensory)