Facial pain

Professor Kareem M Altameemi

Learning objectives

1. To know the pathophysiology of facial pain.*

2.To know the important points in the history and examination ***

3.To know the cause of facial pain.***

Pathophysiology:

Within the skull , the dura (including the dural sinuses , falx cerebri and
the proximal part of large blood vessels) are the main structures sensitive to
pain. Mostly innervated by trigeminal nerve . This probably accounting for
the pattern of pain referral seen in intracranial diseases , when these
sensitive parts of the intracranial content are stretched , distended or
otherwise irritated .

Diagnostic approach :
History :(Important point)

1- Over all pattern (Time pattern)

*Onset (sudden , gradual)

*Circadian ( day , night ,random)

*coarse (constant , slowly // rapidly progressive, paroxysmal , reccurent)

2. Tempo of onset : sudden vs gradual

3. Duration and periodicity

4. Effect of posture , cough and straining

5. Localization of pain and radiation e.g within nerve distribution

6. Aggravating and relieving factor : effect of hot, cold, sweet food, prolong
chewing, eating, brushing of teeth, touching of face, weather, physical
activity, posture, stress and tiredness.

7.Quality : dull, sharp, shock-like, electric, burning

8. Intensity, impact of pain on the patient (sleep, mood, fatigue etc

9. Associated symptoms : skin lesions, eye symptoms, nasal discharge

10. family, social, past medical, Past surgical, history of trauma or dental
procedures all are important and may give clue to the diagnosis

Clinical classification
A. Unilateral episodic orofacial pain

1. TN : classical or type 1 ***

2. TN symptomatic e.g. MS, or tumors***

3. TN plus concomitant pain i.e. pain which is dull between the attacks***

4. GPN

5. Trigeminal autonomic cephalgias: such as cluster headache, SUNA,

SUNCT, paroxysmal hemicania , hypnic headache, hemicranias continua
6. Episodic migraine: less than 15 MHDs

B. Non unilateral episodic orofacial headache

1. Tension headache

2. Medication overuse headache***

C. Unilateral continuous orofacial headache

1. Post herpetic neuralgias**

2. Post traumatic trigeminal pain

3. Anesthesia dolorosa

4. Atypical odontalgia

5. Referred pain

6. Post stroke headache, Giant cell arteritis***

7. Chronic migraine

8. Cancer pain

D. Bilateral continuous orofacial pain

1. TMD ***

2. Persistent orofacial muscle pain

3. Burning mouth syndrome

4. Persistent idiopathic facial pain*

EXECISE
A 60-year-old man presents with severe stabbing pain in his right cheek of
several weeks duration. This pain occurs several times a day, lasts for a few
seconds, and it is very intense. Episodes of pain can sometime be
precipitated by touching the face or shaving. What is the most likely
diagnosis?

a. Carotid artery aneurysm

b. Post herpetic neuralgia

c. Trigeminal neuralgia

d. Glossopharyngeal neuralgia

e. Brain tumors

A 35-year old women presents with preauricular facial pain of one month
duration. On examination there is limitation of jaw movement and
tenderness of the muscles of mastication. The pain is dull and continuous
and the patient has backache in addition. What is the next step in the
management of this patient

a. Psychiatric assessment

b. X-ray of TMJ

c. Intra articular injection of steroid

d. Use of NSAID

e. Order CT scan of the joint