Facial pain

Head, neck, and orofacial pain classifications 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 disorders - Neurovascular headache disorders: Primary headache Secondary headache - Neuropathic pain disorders: Proxysmal pain disorders Continuous pain disorders - Headache attributed to associated extracranial pain disorders: Eye, ear, nose, sinuses, and throat disorders - Extracranial intraoral pain disorders Teeth and periodontal disorders Mucogingival, tongue, salivary gland disorders - Musculoskeletal pain disorders - Cervical disorders - Temporomandibular disorders: Articular disorders Muscular disorders

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

Trigeminal neuralgia Definition Epidemiology Disorder of the fifth cranial nerve leading to intense paroxysmal pain within one or more divisions of its sensory supply. Epidemiology 3-6/100.000, more common in female. Incidence of severity increase with age. Usual age of onset 50-70 years

Trigeminal neuralgia Cause: Clinical: compression of trigeminal nerve root by artery in middle cranial fossa nerve demyelination Clinical: Paroxysmal pain within one of the three divisions of trigeminal n, usually maxillary and mandibular divisions. intense, lancinating, burning pain, ‘’ like an electric shock) Pain last seconds to minutes only Frequency varies, may be multiple times/hour Almost always unilateral Many patients have a trigger point for their pain, which may be stimulated by everyday tasks, such as eating, talking and washing Patients have periods of remission and relapse, but symptoms tend to worsen over time. Neurological examination shows no clinical abnormality

Medical management (first line) Trigeminal neuralgia Investigation Full neurological examination MRI brain if: Atypical features Possible underlying demyelinating disease or intracranial lesion Microvascular decompression Treatment: Medical management (first line) Anticonvulsant, such as carbamazepine, phenytoin or gabapentin, or a combination. Carbamazepine started as 100 mg twice daily, up to 1600mg/day monitor WBC and liver function require close follow-up and trial reductions of therapy once symptom free

Trigeminal neuralgia Surgical Management Peripheral procedures eg. cryotherapy/ chemical destruction with alcohol/ phenol. Radiofrequency ablation to affected branch under LA / GA central neurosurgical procedures. Artery causing nerve compression is separated from nerve using Teflon sheet Gamma knife (radiosurgey) All the above carry risks of permanent paraesthesia, anaesthesia dolorosa (sever continous pain within the distribution of the nerve), and risks associated with the surgical procedure itself. Therefore the surgical approach applied when medical management side effect are intolerable

Migraine Definition primary recurrent headache disorder, more common in females. Termed hemicrania as it effects half of the head. Cause possibly related to abnormal 5-hydroxytryptamine (5-HT) receptors activity leading initially to vasoconsitrction of portions of cerebral arteries followed by compensatory vasodilation with cerebral oedema and pain. Precipitants include: Hormonal factors Dietary, e.g chocolate, bananas stress sleep deprivation Bright or flashing lights

Migraine Treatment Clinical signs and symptoms May have preceding aura: visual hallucination, including flashing coloured lights, loss colour perception or other visual disturbances motor- temporary muscle palsies speech disorders including aphasia Sever unilateral headache : Initially poorly localised Becomes localised to temporal, frontal or orbital region. Photophobia Nausea Vomiting Treatment Acute attack: analgesics, sumatriptan (5-HT antagonist), ergot derivatives. Prophylaxis: options include pizotifen (antihistamine), propanolol calcium channel blockers.

Cluster Headaches Definition Recurrent headaches typically around the eye.also known as migrainous neuralgia and Horton’s syndrome. Occur in intermittent bouts with interspersed periods of remission. Often positive family history. 80% patients smoke. Presents in third or fourth decade. Epidemiology Less common than migraine. male: female = 6:1 Cause Unknown. Possible allergic basis with mast cell release of histamine and vasodilatation, Associated with: sleep apnoea and decrease oxygen saturations. Alcohol Cocaine

Cluster Headaches Clinical sign and symptom: Severe, unilateral episodes of burning or lancinating pain, in and around the orbit, frontal and temporal region. Sudden onset, lasts for 15min – 3 hours, often awakens the patient at night. Begin at same time every day (Alarm clock headache) May have multiple episodes each day Occur for 2- 3 months, then have periods of remission that can last for years. May be associated with autonomic problems: Conjunctival vessel congestion Eye watering and swelling around the eye Nasal congestion Facial flushing

Cluster Headaches Investigation Diagnosis is clinical. However similar symptoms may be secondary to intracranial pathology, so consider MRI of the brain. Treatment Acute attack: 1- Oxygen may abort an attack and its effectiveness is diagnostic 2- Subcutaneous or intranasal Sumitriptan Prophylaxis: Nifedipine Ergotamine

Temporal (giant cell) arteritis Definition Multifocal vasculitis affecting the cranial arteries, of unkown aetiology, with average age of onset 70 years. Most common in females over 50 (genetic predisposition). Clinical signs and symptoms Unilateral headache, initially burning in character, becoming throbbing Usually temporal or occipital artery are affected. It can cause occlusion of the arteries and ischemia. Lingual, facial and maxillary arteries may also become involved leading to claudication in eating and talking (pain in jaw when chewing) Affecting vessels feel hard and tender Tongue may become ischaemic if lingual arteries involved 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 sign.

Temporal (giant cell) arteritis Investigation Increase ESR (60-100) Increase ALP- alkaline phosphatase Platelete may also be elevated. Normocytic, Normochromic anaemia Artery biopsy: The gold standard for diagnosing temporal arteritis is biopsy .Usually superficial temporal vessels under LA Giant cell infilitrated lesions seen Treatment 60-100mg prednisolone 1mg/kg/daily start before temporal artery biopsy with aim to preserve vision. Decrease steroid dose with resolution of headache and normalization ESR (may take months or years)

Atypical facial pain Definition Diagnosis of exclusion. Also termed atypical facial neuralgia,or chronic idiopathic facial pain. It is constant, chronic pain in the absence of identifiable organic disease. More common in female. Most patients are middle aged or elderly. Clinical Often difficult for patients to describe symptoms Most frequently described as deep, constant ache or burning Does not stop patients sleeping Does not follow anatomical patterns: May be bilateral Can cross midline Infrequently move to another site Maxilla more than mandible Often initiated/ exacerbated by dental treatment Examination entirely normal

Atypical facial pain Investigation All imaging (including intracranial MRI), bloods, and biopsies are normal Treatment Often unrewarding with limited response Tricyclic antidepressants have some effect in some patients About 30% will respond to gabapentin The involvement of a pain team with access to psychological therapy may help patients to manage their pain

Burning mouth syndrome Definition Burning sensation of oral mucosa, usually tongue, in absence of any identifiable clinical abnormality or cause Epidemiology 5 per 100.000. can be higher in middle aged and elderly patients. Female affected more than male. Cause Unknown, but abnormal factors, anxiety and stress have been implicated. May related to problems with taste and sensory nerves of the peripheral or central nervous system.or some time related nutritional deficiencies, such as a lack of iron, zinc, folate, vit.B1,B2,B6,B12. Fungal infection of the mouth Clinical complain of dry mouth with altered or bad taste Burning sensation affected tongue and anterior palate May be aggravated by certain foods, food flavorings, dyes or dental-work substances usually bilateral and does not awake patient but often present on awaking examination entirely normal

Burning mouth syndrome Investigation Full blood count Haematinics (iron, B12, and folate) Swab for candida All clinical investigations, including bloods and swabs, are normal Treatment Reassurance: patients are often cancerophobic Avoidance of stimulating factors Some patients may respond to tricyclic antidepressants Conginitive behavioural therapy may help and manage their symptoms as medical management is often disappointing