Trigeminal Nerve Distribution Pain in MS: A Novel Association With Trigeminocervical Complex Demyelination
Bianca Albites Coen1, Mark Keegan1, Purnashree Chowdhury1, Narayan Kissoon1
1Mayo Clinic
Objective:
To evaluate the association between trigeminal pain in people with multiple sclerosis (pwMS) and demyelinating lesions involving the trigeminocervical complex (TCC).
Background:
Trigeminal neuralgia (TN) and central neuropathic facial pain (CNP) are recognized complications of MS, with TN typically associated with lesions at the trigeminal root entry zone and CNP with lesions in the brainstem or ascending trigeminal pathways. The TCC is a continuous region extending from the pons to the C3 level, where trigeminal and cervical sensory afferents converge. Lesions within this broader region may contribute to trigeminal pain in pwMS.
Design/Methods:
Participants were selected from a prospective, consecutively accrued cohort of pwMS: cases exhibited trigeminal pain whereas controls did not. Trigeminal pain was diagnosed according to the International Classification of Headache Disorders (ICHD-3) and categorized as TN, CNP, or TN+CNP. Brain and cervical cord MRIs were reviewed to evaluate lesion presence, laterality, and location along the TCC. In cases, lesions were categorized as ipsilateral-to-pain or contralateral-to-pain, whereas in controls, lesions were analyzed regardless of laterality.
Results:
A total of 658 participants were included, of whom 28 (4.3%) had trigeminal pain: 18 (2.7%) TN, 6 (0.9%) CNP, and 4 (0.6%) TN+CNP. Ipsilateral-to-pain TCC lesions were more frequent in cases than in controls (100% vs. 71.2%, p<0.0001), whereas contralateral-to-pain lesions did not differ significantly (75.0% vs. 71.2%, p=0.827). Within the TCC, ipsilateral-to-pain brainstem lesions were also significantly more frequent in cases (75% vs. 46.5%, p=0.005). Notably, all patients without brainstem lesions exhibited at least one ipsilateral-to-pain C1-C3 lesion.
Conclusions:
Although brainstem lesions show the strongest association with trigeminal pain in pwMS, lesions involving the TCC and extending into the upper cervical cord may also contribute. These findings support the use of a more comprehensive imaging evaluation from pons through upper cervical cord to improve identification of the anatomical correlates to trigeminal pain in pwMS.
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