13 - Facial Pain

Question 1

Classification of Facial Pain & Headaches

Answer 1

Facial Pain (Fonseca)

• Somatic
  
  • Musculoskeletal
    
    • TMJ
    • Dentoalveolar/Periodontal
  • Visceral
    
    • Pulpal
• Neuropathic
  
  • Neuralgia
  • Neuroma
  • Burning mouth syndrome
• Psychological
  
  • Idiopathic facial pain

Headaches (International headache society)

• Primary
  
  • Migraine
    
    • with aura
    • without aura
  • Tension-type headache
  • Trigeminal autonomic cephalagias
    
    • Cluster headaches
    • Paroxysmal hemicrania
    • SUNCT
    • Hemicrania continua
  • Other primary headache disorders
• Secondary
  Headache attributed to:
  
  • Trauma or injury
  • Vascular
  • Infection
  • Hemeostasis
  • Withdrawal
  • Disorder of the head and neck
  • Psychiatric disorder

Question 2

Facial Pain Definitions

Allodynia
Analgesia
Paresthesia
Anaesthesia
Dysesthesia
Hyperalgesia
Hyperesthesia
Neuralgia
Neuropathy

Answer 2

• Allodynia - Pain caused by a stimulus that does not normally provoke pain
• Analgesia - Absence of pain in response to stimulation that would normally be painful
• Paresthesia - Abnormal sensation, whether spontaneous or evoked
• Anaesthesia - Absence of all sensation
• Deafferentation pain - Pain caused by loss of sensory input into the central nervous system
• Dysesthesia - Unpleasant abnormal sensation whether spontaneous or evoked
• Hyperalgesia - Increased sensitivity to noxious stimuli
• Hyperesthesia - Increased sensitivity to all stimulation, excluding special senses
• Neuralgia - Pain in the distribution of a nerve or nerves
• Neuropathy - Disturbance of function or pathologic change in a nerve

Pain physiology involves several aspects:

• Transduction - Activation of special nerve endings
• Transmission - Transmission of the signal to the cortical centre (Thalamus)
• Modulation -

Question 3

Trigeminal Neuralgia

Answer 3

Classification:

• TN1 - Characterized by attacks of intense, stabbing pain affecting the mouth, cheek, nose and/or other areas of the face
• TN2 - Characterized by less intense but constant dull aching or burning pain

Question 4

Migraines

Answer 4

Migraines

• Diagnostic criteria (International headache society)
  
  • At least five attacks fulling the following
  • Head attacks lasting 4-72hrs
  • Headache having at least two of the following characteristics
    
    • Unilateral location
    • Pulsating quality
    • Mod or severe pain intensity
    • aggravation by or causing avoidance of routine physical activity
  • During headaches at least one of the following
    
    • Nausea and/or vomiting
    • Photophobia or phonophobia
  • Not better accounted for by another diagnosis

Question 5

Temporal Arteritis

Answer 5

• Definition
  
  • Vasculitis of large and medium arteries of the head and extra-cranial arteries above the aortic arch
• Epidemiology
  
  • >50 yrs of age
  • F > M
  • 50% associated with Polymyogia rheumatica
• Pathophysiology
  
  • Associated with HLA DR4 (Same as Rheumatoid Arthritis)
• Diagnosis
  
  • American college of rheumatology
    HEAPS
    Requires 3 out of 5
    
    • Hemicranial headaches
    • ESR >50
    • Age > 50
    • Positive Biopsy - Superficial temporal artery
    • Scalp tenderness - over Superficial temporal artery
• Biopsy
  
  • At least 2cm
    The longer the length the better
  • Same side is best
  • Can use contralateral Superficial temporal artery
• Histology
  
  • Multinucleate giant cells, granulomatous inflammation of intima and media of the vessel
  • Narrow artery and necrosis of the smooth vessel
    ​
• Treatment
  
  • Prednisolone pulse - 50mg
    
    • Do not delay for biopsy
  • Immunosuppressant - Monoclonal antibodies - Restricted behind a positive biopsy