Facial pain Facial pain

Introduction

Head, neck, and orofacial pain classifications • Intracranial disorders 1- Neurovascular headache disorders 2- Neuropathic pain disorders

• Extracranial pain disorders 1- Intraoral pain disorders 2- Musculoskeletal cervical and temporomandibular disorders 3- Cervical spine disorders 4- Temporomandibular disorders 5- Muscular disorders Local myalgia Myofascial pain Centrally mediated myalgia Myospasm Myositis and tendonitis Muscle contracture Muscle neoplasia

Intracranial and vascular pain disordersNeurovascular headache disorders:Primary headacheSecondary headacheNeuropathic pain disorders:Proxysmal pain disordersContinuous pain disorders

Headache attributed to associated extracranial pain disorders:Eye, ear, nose, sinuses, and throat disordersExtracranial intraoral pain disordersTeeth and periodontal disordersMucogingival, tongue, salivary gland disordersMusculoskeletal pain disordersCervical disordersTemporomandibular disorders:Articular disordersMuscular disorders

Investigations Investigations • clinical signs and symptomsclinical signs and symptoms• clinical examinationsclinical examinations• Radiographic exam, CT or/and MRI Radiographic exam, CT or/and MRI

Trigeminal neuralgiaTrigeminal neuralgia

DefinitionDefinitionDisorder of the fifth cranial nerve leading to intense Disorder of the fifth cranial nerve leading to intense

paroxysmal pain within one or more divisions of its paroxysmal pain within one or more divisions of its sensory supply.sensory supply.

EpidemiologyEpidemiology3-6/100.000, more common in female. Incidence of severity 3-6/100.000, more common in female. Incidence of severity

increase with age. Usual age of onset 50-70 yearsincrease with age. Usual age of onset 50-70 years

Trigeminal neuralgiaTrigeminal neuralgia

Cause:Cause:• compression of trigeminal nerve root by artery in middle cranial fossacompression of trigeminal nerve root by artery in middle cranial fossa• nerve demyelination nerve demyelination

Clinical:Clinical:• Paroxysmal pain within one of the three divisions of trigeminal n, usually maxillary Paroxysmal pain within one of the three divisions of trigeminal n, usually maxillary

and mandibular divisions.and mandibular divisions.• intense, lancinating, burning pain, ‘’ like an electric shock)intense, lancinating, burning pain, ‘’ like an electric shock)• Pain last seconds to minutes onlyPain last seconds to minutes only• Frequency varies, may be multiple times/hourFrequency varies, may be multiple times/hour• Almost always unilateralAlmost always unilateral• Many patients have a trigger point for their pain, which may be stimulated by Many patients have a trigger point for their pain, which may be stimulated by

everyday tasks, such as eating, talking and washingeveryday tasks, such as eating, talking and washing• Patients have periods of remission and relapse, but symptoms tend to worsen over Patients have periods of remission and relapse, but symptoms tend to worsen over

time.time.• Neurological examination shows no clinical abnormalityNeurological examination shows no clinical abnormality

Trigeminal neuralgiaTrigeminal neuralgia

InvestigationInvestigation• Full neurological examination Full neurological examination • MRI brain if:MRI brain if:

Atypical featuresAtypical features

Possible underlying demyelinating disease or intracranial lesionPossible underlying demyelinating disease or intracranial lesion

Microvascular decompression Microvascular decompression

Treatment:Treatment:Medical management (first line)Medical management (first line)• Anticonvulsant, such as carbamazepine, phenytoin or gabapentin, or a Anticonvulsant, such as carbamazepine, phenytoin or gabapentin, or a

combination.combination.• Carbamazepine started as 100 mg twice daily, up to 1600mg/dayCarbamazepine started as 100 mg twice daily, up to 1600mg/day• monitor WBC and liver functionmonitor WBC and liver function• require close follow-up and trial reductions of therapy once symptom free require close follow-up and trial reductions of therapy once symptom free

Trigeminal neuralgiaTrigeminal neuralgia

Surgical ManagementSurgical Management• Peripheral procedures eg cryotherapy/ chemical destruction with alcohol/ Peripheral procedures eg cryotherapy/ chemical destruction with alcohol/

phenol. Radiofrequency ablation to affected branch under LA / GAphenol. Radiofrequency ablation to affected branch under LA / GA• central neurosurgical procedures. Artery causing nerve compression is central neurosurgical procedures. Artery causing nerve compression is

separated from nerve using Teflon sheetseparated from nerve using Teflon sheet• Gamma knife (radiosurgey)Gamma knife (radiosurgey)

All the above carry risks of permanent paraesthesia, anaesthesia dolorosa All the above carry risks of permanent paraesthesia, anaesthesia dolorosa (sever continous pain within the distribution of the nerve), and risks (sever continous pain within the distribution of the nerve), and risks associated with the surgical procedure itself. Therefore the surgical associated with the surgical procedure itself. Therefore the surgical approach applied when medical management side effect are intolerableapproach applied when medical management side effect are intolerable

MigraineMigraine

Definition primary recurrent headache disorder, more common in Definition primary recurrent headache disorder, more common in females. Termed hemicrania as it effects half of the head.females. Termed hemicrania as it effects half of the head.

Cause possibly related to abnormal 5-hydroxytryptamine (5-HT) Cause possibly related to abnormal 5-hydroxytryptamine (5-HT) receptors activity leading initially to vasoconsition of portions of receptors activity leading initially to vasoconsition of portions of cerebral arteries followed by compensatory vasodilation with cerebral arteries followed by compensatory vasodilation with cerebral oedema and pain.cerebral oedema and pain.

Precipitants include:Precipitants include: Hormonal factorsHormonal factors Dietary, e.g chocolate, bananas Dietary, e.g chocolate, bananas stressstress sleep deprivationsleep deprivation Bright or flashing lightsBright or flashing lights

MigraineMigraine Clinical signs and symptoms Clinical signs and symptoms May have preceding aura:May have preceding aura:visual hallucination, including flashing coloured lights, loss colour visual hallucination, including flashing coloured lights, loss colour

perception or other visual disturbancesperception or other visual disturbancesmotor- temporary muscle palsiesmotor- temporary muscle palsiesspeech disorders including aphasia speech disorders including aphasia Sever unilateral headache :Sever unilateral headache :Initially poorly localised Initially poorly localised Becomes localised to temporal, frontal or orbital region. Becomes localised to temporal, frontal or orbital region. Photophobia Photophobia NauseaNausea Vomiting Vomiting

TreatmentTreatment Acute attack: analgesics, sumatriptan (5-HT antagonist), ergot Acute attack: analgesics, sumatriptan (5-HT antagonist), ergot

derivatives.derivatives. Prophylaxis: options include pizotifen (antihistamine), propanolol Prophylaxis: options include pizotifen (antihistamine), propanolol

calcium channel blockers.calcium channel blockers.

Cluster HeadachesCluster Headaches

DefinitionDefinition

Recurrent headaches also known as migrainous neuralgia and Horton’s Recurrent headaches also known as migrainous neuralgia and Horton’s syndrome. Occur in intermittent bouts with interspersed periods of syndrome. Occur in intermittent bouts with interspersed periods of remission. Often positive family history. 80% patients smoke. Presents in remission. Often positive family history. 80% patients smoke. Presents in third or fourth decade.third or fourth decade.

EpidemiologyEpidemiology

Less common than migraine. male: female = 6:1Less common than migraine. male: female = 6:1

CauseCause

Unknown. Possible allergic basis with mast cell release of histamine and Unknown. Possible allergic basis with mast cell release of histamine and vasodilation, Associated with:vasodilation, Associated with:

sleep apnoea and decrease oxygen saturations. sleep apnoea and decrease oxygen saturations. AlcoholAlcohol CocaineCocaine

Cluster HeadachesCluster Headaches Clinical:Clinical:• Severe, unilateral episodes of burning or lancinating pain, in and Severe, unilateral episodes of burning or lancinating pain, in and

around the orbit, frontal and temporal region.around the orbit, frontal and temporal region.• Abrupt onset, lasts for 15min – 3 hours, often awakens the patient at Abrupt onset, lasts for 15min – 3 hours, often awakens the patient at

night.night.• Begin at same time every day (Alarm clock headache)Begin at same time every day (Alarm clock headache)• May have multiple episodes each dayMay have multiple episodes each day• Occur for 2- 3 months, then have periods of remission that can last Occur for 2- 3 months, then have periods of remission that can last

for years.for years.• May be associated with autonomic problems:May be associated with autonomic problems:

Conjunctival vessel congestion Conjunctival vessel congestion

Eye watering Eye watering

Nasal stuffinessNasal stuffiness

Facial flushingFacial flushing

Cluster HeadachesCluster Headaches

Investigation Investigation

Diagnosis is clinical. However similar symptoms may be secondary to Diagnosis is clinical. However similar symptoms may be secondary to intracranial pathology, so consider MRI of the brain.intracranial pathology, so consider MRI of the brain.

TreatmentTreatment• Acute attack: Acute attack:

1- Oxygen may abort an attack and its effectiveness is diagnostic 1- Oxygen may abort an attack and its effectiveness is diagnostic

2- Sumitriptan 2- Sumitriptan

• Prophylaxis: Prophylaxis:

NifedipineNifedipine

ErgotamineErgotamine

Temporal (giant cell) arteritisTemporal (giant cell) arteritis

Definition Definition

Multifocal vasculitis affecting the cranial arteries, of unkown aetiology, with Multifocal vasculitis affecting the cranial arteries, of unkown aetiology, with average age of onset 70 years. Most common in females over 50 (genetic average age of onset 70 years. Most common in females over 50 (genetic predisposition).predisposition).

ClinicalClinical

Unilateral headache, initially burning in character, becoming throbbingUnilateral headache, initially burning in character, becoming throbbing

Usually temporal or occipital arteryUsually temporal or occipital artery

Lingual, facial and maxillary arteries may also become involved leading to Lingual, facial and maxillary arteries may also become involved leading to claudication in eating and talking. claudication in eating and talking.

Affecting vessels feel hard and tenderAffecting vessels feel hard and tender

Tongue may become ischaemic if lingual arteries involved Tongue may become ischaemic if lingual arteries involved

If untreated 25% will develop visual problems secondary to central retinal artery If untreated 25% will develop visual problems secondary to central retinal artery involvement, which may be bilateral. Loss of vision may be the first clinical involvement, which may be bilateral. Loss of vision may be the first clinical sign.sign.

Temporal (giant cell) arteritisTemporal (giant cell) arteritis

Investigation Investigation

Increase ESR (60-100)Increase ESR (60-100)

Normocytic, Normochromic anaemiaNormocytic, Normochromic anaemia

Artery biopsy:Artery biopsy:

Usually superficial temporal under LAUsually superficial temporal under LA

Giant cell lesions seenGiant cell lesions seen

TreatmentTreatment

60-100mg prednisolone daily start before temporal artery biopsy with aim to 60-100mg prednisolone daily start before temporal artery biopsy with aim to preserve vision. preserve vision.

Decrease steroid dose with resolution of headache and normalization ESR Decrease steroid dose with resolution of headache and normalization ESR (may take months or years) (may take months or years)

Atypical facial painAtypical facial pain

Definition Definition

Diagnosis of exclusion. Constant, chronic pain in the absence of Diagnosis of exclusion. Constant, chronic pain in the absence of identifiable organic disease. More common in female. Most patients identifiable organic disease. More common in female. Most patients are middle aged or elderly are middle aged or elderly

Clinical Clinical

Often difficult for patients to describe symptomsOften difficult for patients to describe symptoms

Most frequently described as deep, constant ache or burningMost frequently described as deep, constant ache or burning

Does not stop patients sleepingDoes not stop patients sleeping

Does not follow anatomical patterns:Does not follow anatomical patterns: May be bilateral May be bilateral Can cross midlineCan cross midline Infrequently move to another siteInfrequently move to another site

Maxilla more than mandible Maxilla more than mandible

Often initiated/ exacerbated by dental treatmentOften initiated/ exacerbated by dental treatment

Examination entirely normalExamination entirely normal

Atypical facial painAtypical facial pain

InvestigationInvestigation

All imaging (including intracranial MRI), bloods, and biopsies are All imaging (including intracranial MRI), bloods, and biopsies are normalnormal

Treatment Treatment • Often unrewarding with limited responseOften unrewarding with limited response• Tricyclic antidepressants have some effect in some patients Tricyclic antidepressants have some effect in some patients • About 30% will respond to gabapentinAbout 30% will respond to gabapentin• The involvement of a pain team with access to psychological The involvement of a pain team with access to psychological

therapy may help patients to manage their paintherapy may help patients to manage their pain

Burning mouth syndrome Burning mouth syndrome

DefinitionDefinition

Burning sensation of oral mucosa, usually tongue, in absence of any Burning sensation of oral mucosa, usually tongue, in absence of any identifiable clinical abnormality or causeidentifiable clinical abnormality or cause

Epidemiology Epidemiology

5 per 100.000. can be higher in middle aged and elderly patients. Female 5 per 100.000. can be higher in middle aged and elderly patients. Female affected more than male. affected more than male.

CauseCause

Unknown, but abnormal factors, anxiety and stress have been implicatedUnknown, but abnormal factors, anxiety and stress have been implicated

ClinicalClinical• complain of dry mouth with altered or bad tastecomplain of dry mouth with altered or bad taste• Burning sensation affected tongue and anterior palateBurning sensation affected tongue and anterior palate• May be aggravated by certain foodsMay be aggravated by certain foods• usually bilateral and does not awake patient but often present on awakingusually bilateral and does not awake patient but often present on awaking• examination entirely normal examination entirely normal

Burning mouth syndrome Burning mouth syndrome

InvestigationInvestigation • Full blood countFull blood count• Haematinics (Haematinics (iron, , B12, and , and folate) ) • Swab for candidaSwab for candida

All clinical investigations, including bloods and swabs, are normalAll clinical investigations, including bloods and swabs, are normal

TreatmentTreatment

Reassurance: patients are often cancerophobic Reassurance: patients are often cancerophobic

Avoidance of stimulating factorsAvoidance of stimulating factors

Some patients may respond to tricyclic antidepressants Some patients may respond to tricyclic antidepressants

Conginitive behavioural therapy may help and manage their symptoms as Conginitive behavioural therapy may help and manage their symptoms as medical management is often disappointingmedical management is often disappointing