Neuralgia of the trigeminal nerve, vascular algia of the face, temporal arteritis, and influence on driving

Neuralgia of the trigeminal nerve

This condition is most frequent in women and usually starts at 50 years of age; it is characterized by paroxysmal, discontinuous pain, expressed as electrical discharges, stabbing or laceration of the face.

These painful paroxysms, of fulgurating nature, are grouped into bursts forming the fits that last from some seconds to one or two minutes.

During a fit, the patients stops every activity, stops speaking, and his appearance is of extreme suffering.

The pain is unilateral and is first usually limited to a branch of the trigeminal nerve, frequently of the upper maxillary nerve.

During its evolution the entire territory of the trigeminal nerve can be affected. In some cases, the neuralgia of the trigeminal nerve becomes bilateral, with independent evolution.

Speaking, chewing, skin or mucosal contact, or a simple air blow can be the origin of a paroxysmal discharge.

The painful discharges can cause some motor manifestations in the form of sudden muscular shocks.

The medical therapy used is oral carbamazepine, that in some patients can cause adverse reactions including somnolence, stupor, digestive and skin intolerance.

In refractory cases or those with an evident organic cause responsible for the clinical condition, neurosurgical approach is frequently required.

Advice on neuralgia of the trigeminal nerve

• The painful discharges in neuralgia of the trigeminal nerve are disabling for driving.
• We should warn the patient of the side effects of the treatment with carbamazepine, that in some cases can hinder driving.
• The neurological sequels following surgery should be notified in a medical report, to assess the ability to drive of the patient and advise him with this regard.
• We should recommend our patient that, to prevent painful discharges, he should not direct the air conditioning outlet directly to the face, not take chewing-gum while driving, and try to drive calmed, without pressing the jaws.

Vascular algia of the face

Painful episodes are more frequent in men, are related to a significant vascular component, last from some minutes to two hours, and occur daily for months.

The pain is unilateral and intermittent, relatively localized or on the contrary very extensive affecting the eye and periorbital region, the temples, the jaws, the teeth and even the neck.

It can be associated with bloodshot eyes, tearing, rhinorrhea, and more rarely transient Claude Bernard-Horner sign.

The treatment is based on the conventional analgesics, but the most severe cases are relieved with ergotamine, for its vasoconstrictive action in the cephalic arteries.

Precise focal sinus, nasal, or dental injuries require treatment, with variable results in the improvement of pain of the face.

Ergotamine derivatives involve the risk that the patient self-medicates increasing the frequency of doses, with the added risk of vasoconstriction complications, that will be evidence as paresthesia, and cold hands and feet, that lead to immediate drug discontinuation.

Peripheral ischemia due to ergotamine requires urgent medical treatment with vasodilators and heparin.

Advice on vascular algias of the face

• The painful fits in the face of vascular origin are disabling for driving.
• Therapy with ergotamine can relieve pain but has side effects that should be warned to maximize caution when driving.
• The patient should follow the treatment guidelines recommended by his physician, not increasing the dose or its frequency, for the risk of peripheral ischemia that would be disabling for driving.
• In this case, the patient must not drive until this ischemic complication has subsided completely and without sequels.

Horton’s temporal arteritis

Giant cell arteritis is most frequent in the elderly, and therefore should be considered for the increased number of elderly drivers.

Headache is preceded for some days or weeks by a change in the general condition, with diffuse pain.

Headache appears suddenly and paroxysmally in the temporal region, and the hard, painful artery can be felt.

Hypersensitivity of the scalp and visual disorders such as amaurosis fugax, diplopia, scotoma, ptosis, and blurred vision are frequent.

Claudication of the masseter, temporal and tongue muscles are characteristic.

The diagnosis should be made promptly for the risk of blindness due to thrombosis of the ophthalmic artery or of its branches, from spreading of the inflammatory condition to other arteries.

Stroke, coronary symptoms and rheumatic injuries can be seen.

Corticoids can be effective, and headache and its possible complications disappear.

The treatment can be prolonged, with the possible side effects of these drugs in the elderly, also more vulnerable.

In long-term treatments with corticoids, Cushing syndrome, hyperglycemia, osteoporosis, hypertension, edema, psychotic states, muscle atrophy, cataracts, glaucoma, peptic ulcer, digestive bleeding, aseptic bone necrosis, thrombosis, etc., can occur.

Advice on Horton’s temporal arteritis

• Paroxysmal headache of the temporal region is disabling for driving.
• The complications associated with this disease can be serious and permanently disabling for driving.
• An early treatment, continued assessment of the possible sequels, and a medical report with the advice to assess the ability to drive are all very important.
• The osteoporosis caused by long-term treatment with corticoids can worsen the existing disease in the bones due to age, so the patient should be reminded to maximize caution when driving to prevent crashes that, though mild, can cause fractures in their more vulnerable bones.
• With this regard, it would be advisable to always respect the safety distance, to adjust the backing of the seat, the distance to the steering wheel and the headrest, drive short, known distances, and avoid rush hours.
• The complications of corticoids will force the physician to possible changes in therapy and to advise against driving as long as the symptoms interfering with driving persist, as in the case of digestive bleeding, thrombosis, bone necrosis, etc.