Vagoglossopharyngeal Neuralgia Research Articles

Lateral medullary vascular compression manifesting as paroxysmal hypertension

Neurovascular compression of the rostral ventrolateral medulla (RVLM) has been described as a possible cause of refractory essential hypertension. We present the case of a patient affected by episodes of severe paroxysmal hypertension, some episodes associated with vago-glossopharyngeal neuralgia. Classical secondary forms of hypertension were excluded. Imaging revealed a neurovascular conflict between the posterior inferior cerebellar artery (PICA) and the ventrolateral medulla at the level of the root entry zone of the ninth and tenth cranial nerves (CN IX-X REZ). A MVD of a conflict between the PICA and the RVLM and adjacent CN IX-X REZ was performed, resulting in reduction of the frequency and severity of the episodes. Brain MRI should be performed in cases of paroxysmal hypertension. MVD can be considered in selected patients.

Glossopharyngeal and vagoglossopharyngeal neuralgia: Long-term surgical outcomes in a single institution.

Glossopharyngeal neuralgia (GPN) and vagoglossopharyngeal neuralgia (VGPN) are infrequent syndromes that can have great negative impact on a patient's quality of life. The objective of this study is to describe the characteristics and long-term results of patients with GPN-VGPN who are treated surgically with microvascular decompression (MVD) in one institution. This is a retrospective series of 20 patients with the diagnosis of GPN-VGPN who underwent MVD. Demographic characteristics, surgical results, complications, and long-term follow-up were analyzed. The mean age of symptom onset was 51.25 years and the majority of patients were women (60%). The posterior inferior cerebellar artery was the main offending vessel (75%). The immediate MVD success rate was 100%, but during follow-up, two patients (10%) were diagnosed with VGPN and both cases presented pain recurrence. The mean follow-up was 120.4 (25-333) months. VGPN (P = 0.005) and a ≥5 day hospital stay (P = 0.032) were associated with unsuccessful outcomes. Two complications were documented, which resolved without sequelae. There was no surgical mortality. MVD is an effective and safe treatment for long-term pain relief of GPN-VGPN. VGPN and a prolonged hospital stay were associated with poor outcomes. More studies are required to confirm these findings.

Routine postoperative admission to the neurocritical intensive care unit after microvascular decompression: necessary or can it be abandoned?

Postoperative neurocritical intensive care unit (NICU) admission of patients who underwent craniotomy for close observation is common practice. In this study, we performed a comparative analysis to determine if there is a real need for NICU admission after microvascular decompression (MVD) for cranial nerve disorders or whether it may be abandoned. The present study evaluates a consecutive series of 236 MVD surgeries performed for treatment of trigeminal neuralgia (213), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2). All patients were operated by the senior surgeon according to a standard protocol over a period of 12years. Patients were admitted routinely to NICU during the first phase of the study (phase I), while in the second phase (phase II), only patients with specific indications would go to NICU. While 105 patients (44%) were admitted to NICU postoperatively (phase I), 131 patients (56%) returned to the ward after a short stay in a postanaesthesia care unit (PACU) (phase II). Specific indications for NICU admission in phase I were pneumothorax secondary to central venous catheter insertion (4 patients), AV block during surgery, low blood oxygen levels after extubation, and postoperative dysphagia and dysphonia (1 patient, respectively). There were no significant differences in the distribution of ASA scores or the presence of cardiac and pulmonary comorbidities like congestive heart failure, arterial hypertension, or chronic obstructive pulmonary disease between groups. There were no secondary referrals from PACU to NICU. Our study shows that routine admission of patients after eventless MVD to NICU does not provide additional value. NICU admission can be restricted to patients with specific indications. When MVD surgery is performed in experienced hands according to a standard anaesthesia protocol, clinical observation on a neurosurgical ward is sufficient to monitor the postoperative course. Such a policy results in substantial savings of costs and human resources.

Clinical and physiopathological aspects of the glossopharyngeal neuralgia

Introduction Glossopharyngeal neuralgia is a rare syndrome characterized by paroxysms of unilateral and severe stabbing pain occurring in the nerve’s distribution. Although other neuralgias are well described in the medical literature, glossopharyngeal neuralgia and its physiopathology are not. The vascular compression at the nerve root entry zone is the primary explanation for the disease. The first-line treatment is pharmacological, including carbamazepine, oxcarbazepine, and gabapentin. Surgical treatment is offered to medication-refractory patients, and microvascular decompression surgery has the best outcomes. Objective To investigate the pathophysiological and clinical aspects of the different presentations of glossopharyngeal neuralgia. Method: A systematic review of the literature including case reports and clinical trials, was done. Results A search of the literature yielded 31 papers that regarded glossopharyngeal neuralgia or its variants. Eight of these reports regarded vagoglossopharyngeal neuralgia. Seven regarded the glossopharyngeal neuralgia followed by or caused by another disease. Conclusion Glossopharyngeal neuralgia is a rare disease and requires further studies on its mechanism and clinical assessment; the physician needs to know how to distinguish it from its variants and underlying causes.

A CURIOUS CASE OF CARDIAC SYNCOPE: LET'S PAUSE AND TAKE A LOOK

Glossopharyngeal neuralgia (GPN) is a craniofacial syndrome with paroxysms of stabbing pain along the glossopharyngeal nerve. Rarely in 2% of the cases, reflexive autonomic outflow to the vagus nerve causes life-threatening arrhythmias and syncope, called vago-glossopharyngeal neuralgia(VGPN). A 66

Hemifacial spasm associated with other cranial nerve syndromes: Literature review

Hyperactive dysfunction may affect all cranial nerves in the posterior fossa. According to literature review and personal experience, hemifacial spasm was found to be associated not only with the most frequent cranial nerve syndromes, namely: trigeminal neuralgia, vago-glossopharyngeal neuralgia or VIIIth nerve disturbances manifested by vertigo, tinnitus, hearing decrease, but also with rarer syndromes like geniculate neuralgia, masticatory spasm etc. Also, a number of publications have pointed out the relatively high incidence of the coexistence of hemifacial spasm and systemic blood hypertension; both can be cured by vascular decompression of the ventrolateral aspect of the medulla and IX-Xth route entry zone (REZ) together with the facial REZ. Even more complex clinical presentations have been encountered, corresponding to disturbances in several cranial nerve nuclei. Some could be attributed to neurovascular conflicts from elongated arteries invaginated into the brainstem, and cured by microvascular decompression surgery. When confronted with such complex, and therefore misleading, syndrome, it is advised to search for vascular conflicts at the brainstem using high-resolution MRI exploration.

Vagoglossopharyngeal neuralgia revealed through predominant digestive vagal manifestations. Case report and literature review

Vagoglossopharyngeal neuralgia is a rare pathology whose atypical forms, dominated by syncopal manifestations, are still rarer. Although the territory of the vagus nerve involves, beyond the cardiovascular system, the respiratory and the digestive systems, there is no report in literature of atypical forms other than syncopal. Therefore, the authors were prompted to report the case of a patient whose vagoglossopharyngeal neuralgia was predominantly revealed by digestive symptoms. A 58-year-old patient presented with stereotypical severe digestive disturbances including nausea, vomiting and diarrhoea. High definition cranial MRI showed a neurovascular conflict between the posterior inferior cerebellar artery and the IXth and Xth nerves, on the right side. A microsurgical decompression was carried out which confirmed the vascular compression and successful transposition of the artery. One year after the surgery, the patient was free from all painful and digestive symptoms. A survey of the literature did not find any reference to digestive symptoms together with the neuralgia; only a syncopal type of cardiac symptoms related to the parasympathetic nervous system were described. The hypothesis was that the revealing digestive symptoms are linked to a similar parasympathetic mechanism, implying the visceral component of the Xth cranial nerve.

Computed tomography-guided percutaneous trigeminal tractotomy-nucleotomy.

The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively (postoperative Day 1). The best results were obtained in the second-largest group (vagoglossopharyngeal neuralgia, n = 17) and in geniculate neuralgia (n = 4). Patients with atypical facial pain (n = 21; 13 women, eight men) accounted for the largest group to undergo computed tomography-guided TR-NC surgery; pain relief was achieved in 19 of these patients. In the third-largest group (craniofacial and oral cancer pain, n = 13), 11 of 13 patients were successfully treated with TR-NC. Four of five patients with failed trigeminal neuralgia were also effectively treated with TR-NC. We propose that computed tomography-guided TR-NC provides direct visualization of the target-electrode relation and can be considered a first-step procedure in patient management. In view of its high efficacy, low complication rate, and minimal invasiveness, computed tomography-guided trigeminal TR-NC is a safe and effective procedure in the treatment of intractable facial pain syndromes.

NTCT-13VAGOGLOSSOPHARYNGEAL NEURALGIA PRESENTING AS FREQUENT SEIZURE-LIKE SPELLS IN A PATIENT WITH HEAD AND NECK CANCER TREATED WITH HIGH CUMULATIVE RADIATION DOSE

A 62-year-old man presented with six months of numerous seizure-like events with a sequence of light-headedness, tonic extension of the right arm, loss of consciousness, urinary incontinence and convulsion. He had been diagnosed with laryngeal cancer five years prior, treated with definitive radiotherapy 72Gy in 36 fractions to the left glottis. He had local cancer recurrence three years later and was treated with additional surgeries including bilateral neck dissection and a pectoralis major myocutaneous flap. The following year he required extensive surgery for local disease recurrence and additional reconstruction. He underwent a second course of radiation of 60Gy in 30 fractions with concomitant cisplatin as a radiosensitizer. He achieved complete disease remission, with symptoms related to radiation dermatitis, dysphagia, and left ear pain. More than 20 seizure-like spells were documented, beginning fourteen months after final treatment. Many episodes were heralded by acute jaw and throat pain. Physical examination revealed an iatrogenic left hypoglossal nerve deficit, soft palate scarring, and post-radiation changes to the free flap of the neck and throat. During target events, his heart rate was 20 beats per minute and mean arterial pressure was 40-45 mmHg. EEG, brain MRI, and transthoracic echocardiogram were normal. This phenomenology of seizure-like activity led us to consider the rare entity of radiation-related vagoglossopharyngeal neuralgia, given the very high cumulative local radiation dose. We treated him accordingly with midodrine and fludrocortisone after an incomplete response to atropine. Gabapentin, carbamazepine, and aggressive analgesia provided partial relief of his pain attacks. He remained syncope-free for four months and elected hospice at the time of cancer recurrence. There have been rare reported cases of cancer treatment-related glossopharyngeal neuralgia with convulsive syncope. Prompt diagnosis is necessary because it is a treatable life-threatening condition that could be confused for seizure presentation.

Vago-glossopharyngeal neuralgia: a literature review of neurosurgical experience.

Glossopharyngeal neuralgia (GPN), or better named vago-glossopharyngeal neuralgia (VGPN), is a rare disorder amounting to 1 % of the incidence of trigeminal neuralgia (TN). Pain is paroxysmal, of the electrical shooting type, and mainly provoked by stimulation of the pharynx or deep throat, especially during swallowing. Due to its rarity, VGPN is often misdiagnosed. The front line of medical treatment is based on anticonvulsants. Surgery should be considered when the pain is refractory to medications. In most patients, the cause is neurovascular conflict on root entry zone (REZ) or midcistern portion, of the IXth and/or Xth cranial nerves. Compressive vessels can be evidenced by means of a high sensibility and a high specificity resolution MR imaging in most centers. Present consensus is that the first option of neurosurgical treatment be microvascular decompression. In patients with precarious general conditions, stereotactic radiosurgery may be considered. Also, thermo-rhizotomy at the pars nervosa of foramen jugularis or tractotomy-nucleotomy at brainstem may be alternatives, but these methods entail a significant risk of deficits. In this article, the authors reviewed the main literature series on neurosurgical treatments of this disease.

Glossopharyngeal Neuralgia with Syncope Caused by Neurovascular Compression and Demonstration by High-Resolution MR Imaging: A Case Report

Glossopharyngeal neuralgia (GPN) is a rare condition with a reported incidence of 0.7/100000/year (1). It is characterized by paroxysms of lancinating pain localized unilaterally in the base of the tongue, soft palate, throat, and in the lateral and posterior regions of the pharynx, radiating to the ipsilateral ear. The pain can be triggered by swallowing, coughing, yawning, and chewing, and it usually lasts only for seconds (2). Occasionally, GPN can be associated with cardiac syncope, which is caused by asystole or bradycardia in most cases, and possibly by a vasodepressor reaction as well (2, 3). This syndrome may be referred to as vagoglossopharyngeal neuralgia when the cardiac symptoms accompany pain attacks (3). The causes of GPN are diverse and are divided in the two groups. Idiopathic type of GPN is attributed to the compression of cisternal part of glossopharyngeal nerve by intracranial vessels (4). Secondary type is associated with various lesions that affect the glossopharyngeal nerve at different levels of its path at brainstem structures, cisternal branches, and extracranial divisions (5). Here, we present a case of GPN with recurrent syncope by neurovascular compression.

Vagoglossopharyngeal Neuralgia Treated by Microvascular Decompression and Glossopharyngeal Rhizotomy: Clinical Results of 21 Cases

Background: Microvascular decompression (MVD) and rhizotomy are all selected for treating vagoglossopharyngeal neuralgia (VGPN). Nonetheless, controversies still exist about their curative effect on VGPN. Here we evaluate the effectiveness of MVD together with rhizotomy of the glossopharyngeal nerve for the treatment of VGPN. Methods: This study was carried out on 21 patients who were diagnosed with VGPN between the years 2005 and 2010. Patients underwent MVD and glossopharyngeal rhizotomy through a retromastoid keyhole approach. Surgical technique, operation results and complications were our particular concern. Results: Eighteen (85.7%) of 21 patients experienced immediate and complete relief of pain after surgery. In the remaining 3 patients (14.3%), the pain faded away within the following week. No patient complained of dysphonia or dysphagia. All 21 patients reported no change in their outcome at follow-up. Conclusions: Intracranial vagoglossopharyngeal nerve MVD with glossopharyngeal rhizotomy is an effective and safe procedure to treat VGPN.

Cranial nerve vascular compression syndromes of the trigeminal, facial and vago-glossopharyngeal nerves: comparative anatomical study of the central myelin portion and transitional zone; correlations with incidences of corresponding hyperactive dysfunctional syndromes

The aim of this study was to evaluate the anatomy of the central myelin portion and the central myelin-peripheral myelin transitional zone of the trigeminal, facial, glossopharyngeal and vagus nerves from fresh cadavers. The aim was also to investigate the relationship between the length and volume of the central myelin portion of these nerves with the incidences of the corresponding cranial dysfunctional syndromes caused by their compression to provide some more insights for a better understanding of mechanisms. The trigeminal, facial, glossopharyngeal and vagus nerves from six fresh cadavers were examined. The length of these nerves from the brainstem to the foramen that they exit were measured. Longitudinal sections were stained and photographed to make measurements. The diameters of the nerves where they exit/enter from/to brainstem, the diameters where the transitional zone begins, the distances to the most distal part of transitional zone from brainstem and depths of the transitional zones were measured. Most importantly, the volume of the central myelin portion of the nerves was calculated. Correlation between length and volume of the central myelin portion of these nerves and the incidences of the corresponding hyperactive dysfunctional syndromes as reported in the literature were studied. The distance of the most distal part of the transitional zone from the brainstem was 4.19 ± 0.81 mm for the trigeminal nerve, 2.86 ± 1.19 mm for the facial nerve, 1.51 ± 0.39 mm for the glossopharyngeal nerve, and 1.63 ± 1.15 mm for the vagus nerve. The volume of central myelin portion was 24.54 ± 9.82 mm(3) in trigeminal nerve; 4.43 ± 2.55 mm(3) in facial nerve; 1.55 ± 1.08 mm(3) in glossopharyngeal nerve; 2.56 ± 1.32 mm(3) in vagus nerve. Correlations (p < 0.001) have been found between the length or volume of central myelin portions of the trigeminal, facial, glossopharyngeal and vagus nerves and incidences of the corresponding diseases. At present it is rather well-established that primary trigeminal neuralgia, hemifacial spasm and vago-glossopharyngeal neuralgia have as one of the main causes a vascular compression. The strong correlations found between the lengths and volumes of the central myelin portions of the nerves and the incidences of the corresponding diseases is a plea for the role played by this anatomical region in the mechanism of these diseases.

Neuralgia of the glossopharyngeal and vagal nerves: long-term outcome following surgical treatment and literature review

This study describes our experience in the surgical treatment of neuralgia of the glossopharyngeal and vagal nerves. Over the last 19 years, 21 patients underwent surgery. Their case notes were reviewed to obtain demographic information, clinical presentation, surgical findings and early results. All patients were then contacted by telephone for long-term results and complications. Independent analysis of results was carried out by a Neurology team. Ten patients had microvascular decompression (MVD). Four patients had MVD and nerve section. In the remaining seven patients, the glossopharyngeal and first two rootlets of the vagal nerve were sectioned. Nineteen (90%) of 21 patients experienced complete relief of pain immediately after surgery. The remaining patients reported an improvement in their symptoms. There were no mortalities. Four patients experienced short-term complications, which resolved. Two patients were left with a persistent hoarse voice. At follow-up (mean duration of 4 years), there was no recurrence in symptoms. In our experience, surgery is safe and effective for the treatment of vago-glossopharyngeal neuralgia.

Vagoglossopharyngeal-Associated Syncope Due to a Retained Bullet in the Jugular Foramen

Gunshot wounds (GSWs) to the head are frequently fatal. Rarely, the bullet may lodge in the skull base and not cause significant brain injury. Typically, the bullet fragments are felt to be inert and do not require operative extirpation if they are within the bony confines of the skull base. We report the case of a bullet in the jugular foramen causing recurrent syncope that resolved after surgical removal of the bullet. The medical records from a patient who suffered a GSW to the head were retrospectively reviewed and the treatment and outcome documented. In 2000, a 20-year-old man suffered a GSW to the head. Immediate evaluation revealed the bullet in the right skull base at the jugular foramen, but no parenchymal brain injury. One year after the GSW, he began to experience stereotypical spells resulting in loss of consciousness. Extensive cardiovascular workup was normal. In 2002, the patient underwent removal of the bullet. He has been syncope-free since the operation and returned to his career in the military. We believe the retained bullet in this patient was irritating the IX-X cranial nerves, resulting in syncope, similar to the mechanism in vagoglossopharyngeal neuralgia. Removing the bullet relieved the irritation and stopped the syncopal spells.

Traitement neurochirurgical de la névralgie vago-glossopharyngienne

Glossopharyngeal neuralgia, more accurately called vago-glossopharyngeal neuralgia (VGPN) because of the frequent association with pain irradiation in the sensory territory of the vagus nerve, is not always recognized because its incidence is much lower than the incidence of trigeminal neuralgia (100 times more frequent). As in trigeminal neuralgia, when pain becomes resistant to anticonvulsants - its specific medical treatment - VGPN can almost always be cured by surgery. The first option is microvascular decompression, since vascular compression is the main cause of the neuralgia. Percutaneous thermorhizotomy at the foramen jugularis (pars nervosa) is only indicated as a second option, because of unavoidable sensorimotor deficits in the ninth and tenth nerves. Tractonucleotomies at the medullary level should be reserved essentially for pain of malignant origin.

COMPUTED TOMOGRAPHY-GUIDED PERCUTANEOUS TRIGEMINAL TRACTOTOMY-NUCLEOTOMY

Abstract Objective: The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. Methods: In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients’ pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively (postoperative Day 1). Results: The best results were obtained in the second-largest group (vagoglossopharyngeal neuralgia, n = 17) and in geniculate neuralgia (n = 4). Patients with atypical facial pain (n = 21; 13 women, eight men) accounted for the largest group to undergo computed tomography-guided TR-NC surgery; pain relief was achieved in 19 of these patients. In the third-largest group (craniofacial and oral cancer pain, n = 13), 11 of 13 patients were successfully treated with TR-NC. Four of five patients with failed trigeminal neuralgia were also effectively treated with TR-NC. Conclusion: We propose that computed tomography-guided TR-NC provides direct visualization of the target-electrode relation and can be considered a first-step procedure in patient management. In view of its high efficacy, low complication rate, and minimal invasiveness, computed tomography-guided trigeminal TR-NC is a safe and effective procedure in the treatment of intractable facial pain syndromes.

Vocal Cord Paralysis Following Section of Rami Communicans Vagoglossopharyngeal for Pharyngalgia and Otalgia

A 46–year–old man experienced severe lancinating pain in the throat that radiated to the left ear. The pain, which was exacerbated by swallowing or coughing, had lasted for 2 years. The findings of the patient's neurological examination were normal. Computed tomographic and magnetic resonance imaging scans of the brain and nasopharynx did not show any abnormality. A diagnosis of idiopathic vagoglossopharyngeal neuralgia was made. In surgery, both the glossopharyngeal and the rami communicans between the vagal and grssopharyngeal nerves were sectioned. The patient was free of pain following the surgery, but complained of hoarseness in voice. Examination showed paralyzed left vocal cord at a paramedian position. In the 12 months following the surgery, the hoarseness has gradually improved and eventually disappeared.

Computed tomography-guided trigeminal tractotomy-nucleotomy in the management of vagoglossopharyngeal and geniculate neuralgias.

Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia. Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients. Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC. The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.

Trigeminal Neuralgia

Trigeminal neuralgia, also known as tic douloureux, is an idiopathic condition of severe, unilateral, paroxysmal facial pain. The abrupt nature of the painful attacks (a temporal profile that is similar to that of seizures) led to the discovery that some anticonvulsant drugs are effective against neuralgia.Carbamazepine is the drug of choice, and treatment requires careful dosage titration. Baclofen, phenytoin and sodium valproate are also effective. Transient relief is sometimes possible with local anaesthetics. Limited data suggest that topical capsaicin, and tizanidine, lamotrigine, oxcarbazepine, pyridostigmine and enalapril have helped some patients. While effective, other drugs are limited by their adverse effects; for example, clonazepam is too sedating, pimozide induces extrapyramidal adverse effects, and tocainide and felbamate can cause aplastic anaemia. Phenobarbital (phenobarbitone), opioids, mexiletine, tricyclic antidepressants, corticosteroids, nonsteroidal anti-inflammatory drugs and sympatholytics are ineffective.The antineuralgic effect of any drug may eventually wear off. If this occurs, combination therapy can restore pain relief, as can the reintroduction of a previously effective drug following a drug-free interval.Similar pharmacological strategies potentially apply to other paroxysmal pain syndromes such as vagoglossopharyngeal neuralgia. Clinical overlap with multiple sclerosis or cluster headache suggests additional drugs that may be useful in specific patients. Effective neurosurgical procedures exist for patients with trigeminal neuralgia that is refractory to medications.