Chronic facial pain Flashcards
What are the three dimensions of pain?
Sensory
Motivational
Cognitive
What does allodynia mean?
Pain due to a stimulus that does not normally provoke pain.
What does hyperalgesia mean?
heightened pain from a stimulus that does usually produce pain
What is paresthesia?
An abnormal sensation, whether spontaneous or evoked.
What is dysthesia?
an unpleasant abnormal sensation
what is neuralgia?
A paroxysmal and often severe pain in the distribution of a sensory nerve or nerves.
What is neuropathic pain?
Pain caused by a lesion or disease of the somatosensory nervous system.
What is neuropathy?
A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.
What is the definition of chronic pain?
Longer than 3 months
Which sub group of people is chronic pain more commen in?
Pain with prominent psychosocial dysfunction: Mood disorders. Affective disorders eg. Depression
Anxiety disorders. Disorders in which a certain situation or place triggers excessive fear and/or anxiety symptoms eg. generalized anxiety disorders.
What is somatization?
Somatization is the presentation of physical symptoms as a manifestation of psychological distress.
Symptoms are usually unexplained or
What the main neuralgias of the head and neck which cause pain?
Trigeminal neuralgia
Post herpetic neuralgia
What are the primary headache syndroms,vascular disorders and cerebrospinal fluid syndromes that cause pain?
Classic Migraine (Migraine with Aura)
Common Migraine (Migraine without
Aura)
Migraine Variants
Carotidynia
Mixed Headache
Cluster Headache
Paroxysmal Hemicrania
Temporal Arteritis (Giant Cell Arteritis)
What types of pain is associated with physchosocial cause?
Chronic pain
What is primary trigeminal neuralgia?
Sudden, severe, recurrent stabbing pains in the distribution of one or more branches of the Vth cranial nerve.
Always effects the primary afferant neurone
What type of pain is associated with trigeminal neuralgia?
Sharp, agonizing electric shock-like stabs or pain felt superficially in the skin or buccal mucosa.
usually there are triggers
What is the time pattern of trigeminal neuralgia?
Only for a couple of seconds but can happen every couple of mins for a period
What is the site of the pain caused in trigeminal neuralgia?
Unilateral (95% of the time)
Path of 5th cranial nerve
Often only affects one of the 3 divisions but occasional two.
The most common divisions that it affects are Maxillary, then mandibular then opthalmic
What are the differential diagnosis of trigeminal nerualgia?
Secondary trigeminal neuralgia- tumour,anuerysm
Multiple sclerosis
What is the treatment for trigeminal nerualgia?
Carbamazepine
Oxcarbazepine
Gabapentin
Lamotrigine
Phenytoin
Baclofen
What is the surgical treatment for trigmeminal neuralgia?
Glycerol nerve blocks
Partial sensory
rhizotomy
Radiofrequency ablation of the trigeminal ganglion
Microvascular decompression
What is glossopharyngeal neuralgia?
Paroxysmal bursts of sharp, lancinating pain felt in the distribution of CNIX, particularly the throat, tonsillar fossa and adjacent area of fauces.
Spontaneous or evoked, often by coughing or swallowing.
How can you treat glossopharyngeal neuralgia?
application of local anaesthetic to
What is this? what is the pain characterised by?
Post herpatic nerualgia.
What type of pain does post herpatic nerualgia cause?
Constant pain of moderate intensity but the constant nature makes it intolerable and consquently depression can ensue.
How can you prevent primary herpatic neuralgia?
high-dose aciclovir during initial Herpes Zoster (shingles) episode.
How can you treat post herpatic neuralgia?
Amitriptyline, Pregabalin, topical lignocaine or capsaicin patches. Success rates of treatment are low.
What pain is associated with TMJDS?
Aching in the muscles of mastication, sometimes with an occasional brief severe pain on chewing, often associated with restricted jaw movement and clicking or popping sounds.
unilateral
dull and achy but can be constant
What are the signs of TMJDS?
Restricted mandibular opening with or without deviation of the jawto the affected side on opening
Tenderness to palpation of the muscles of mastication
Clicking or popping at the joint on auscultation or palpation Changes in the ability to occlude the teeth fully.
What imaging can be used for patients with TMJDS?
plain film or MRI.
On the plain film you may see degenerative changes.
On an MRI you may see disk displacement
How do you manage TMJ disorders?
Occlusal splints
Heat packs
TMJ exercises and massage
Medications
- NSAIDs (topical/systemic)
- Anxiolytics, TCAs
Psychotherapy
Surgical options
What are the exacerabating factors of a tension headache
Emotional stress
Anxiety and depression
Physical exercise
Alcohol (which may also have the opposite effect).
What is the managment of tension headaches?
Relaxation techniques
Analgesics
Anxiolytics may help but should generally be avoided since some patients become depressed and others develop dependence.
Tricyclic antidepressants e.g. amitriptyline.
What is Atypical facial pain?
A chronic facial pain of unknown aetiology.
How to manage atypical facial pain?
Reassurance
Topical measures:
Difflam, lignocaine and capsaicin patches
TCAs, other antidepressant meds
Gabapentin, pregabalin
Alternative therapies
Pain team involvement
Psychotherapies
What is atypical odontalgia?
Pain from a tooth with no associated pathology
Throbbing pain, may be moderate to severe but constant
Can change location from tooth to tooth.
What are the associated factors with atypical odontalgia?
TMJDS, oral dysaesthesia, and pains of psychological origin. Often excessive concern with oral hygiene.
How do you manage atypical odontalgia?
Same as atypical facial pain
What is oral dysthesia?
Unpleasant abnormal sensation of oral tissues. Burning Mouth Syndrome is a burning pain in the tongue or other oral mucous membranes.
Most often tip and lateral surface of the tongue but can occur in all of the mucosal areas.
what are the associated symptoms with oral dysthesia? what investigations should be done?
Dry mouth
Persistent dysgeusic taste, altered taste perception, thirst
Burning increased with tension, fatigue, speaking, and hot food, and decreased with sleeping
Denture intolerance
Bloods – anaemia, haematinic deficiency, diabetes, CT disease
Swab – candidal infection
How do you manage oral dysthesia?
Correction of any underlying pathology
Topical rinses – Difflam, Zinc sulphate Vitamin B Co-Strong
TCAs
Gabapentin, pregabalin
Alternative therapies Psychotherapies
What are the three types of migraine?
Classic migraine
Common migraine
Complicated migraine
What are the symptoms of a classi migraine?
Attacks of throbbing head pain preceded by an aura.
The aura is often visual disturbances
Pain is typically unilateral, starting in the fronto-temporal
unaltered by medications and can last upto 75 hours
What are the precipitating factos of a classic migraine? what are the signs and symptoms?
Stress, mood changes, relaxation, dietary causes (chocolate, alcohol, cheese, citrus fruits, etc.), flashing lights, atmospheric changes i.e. noise/smoke
nausea, anorexia, photophobia
How to manage migraines?
NSAIDS/Paracetamol
Anti-emetics
Ergot preparations
Prophylactic Beta-blocking agents i.e. propranolol or seretonin antagonists i.e. pizotifen Serotonin 1D receptor agonists like sumatriptan
What is a cluster headache?
Excruciatingly severe attacks of unilateral headache, principally in the ocular, frontal and temporal areas, recurring in separate bouts with daily, or almost daily, attacks for weeks to months, usually with autonomic symptoms and signs on the symptomatic side.
80-90% male
The pain is constant, stabbing, burning, or even throbbing.
A cluster period usually occurs every 6-18 months
What are the associated signs and symtoms with cluster headaches
ipsilateral ptosis
A reduction in heart rate
Runny nose
How do you manage cluster headaches?
Ergot preparations
Oxygen inhalation
Intranasal lignocaine
Corticosteroids, Verapamil, Lithium or Pizotifen prophylaxis
Serotonin 1D receptor agonists
i.e. Sumatriptan (S/C)
What is temporal arteritis?
A vasculitis affecting branches of the External Carotid Artery with resulting obliteration of the vessel lumen and ischaemia of the part supplied.
unilateral or bilateral
Continuous aching or throbbing
can be associated with polymyalgia rheumatica
Associated signs and symptoms with temporal arteritis?
The temporal artery on the symptomatic side may be pulseless, tender to palpation, bulging and irregular in its appearance.
Involvement of the Cenral Retinal Artery can lead to reduced visual acuity - an “alarm” situation needed immediate therapy (corticosteroid therapy) to prevent permanent blindness.
Chewing can become deficient towards the end of the meal, masticatory ischemia. can get gangrene
How do you manage and investigate temporal arteritis?
A temporal artery biopsy may reveal giant cell arteritis (unreliable)
Raised ESR. (erthyrocyte sedimentation rate)
Treat-
Corticosteroids
Immunosuppressive therapy e.g. azathioprine therapy
Carbemazepine is a commom medication used for chronic facial pain. What dosage should be given?
Initially 100-200mg od- bd
Max dose 1.6g/24hrs
Side-effects:
N&V, Dizziness, Ataxia
Headache, confusion
Blood dyscrasias,hyponatraemia
Rash, Stevens-Johnson Syndrome, TEN
Hepatitis, Acute renal failure
what is the dosage and the side effects of oxcarbazepine?
300mg bd
Max dose
46mg/kg/24hrs
Side-effects:
Similar however usually better tolerated than Carbamazepine
what is the side effects and dosage of gabapentin?
Day 1: 300mg od
Day 2: 300mg bd
Day 3: 300mg tds
Max dose 3.6g/24hrs
Side-effcts:
D&N&V, abdo pain
Weight gain, HTN, Hyperlipidaemia
Dizziness, confusion, headaches, peripheral oedema
Dose and side effects of pregabalin?
75mg bd
** Max dose**
600mg/24hrs
Side-effects: As gabapentin however generally better tolerated.
Dose and side effects of lamotrigine?
25mg od
Max dose 500mg daily
Side-effects:
Rash, hypersensitivity
Stevens-Johnson Syndrome, TEN
Hepatic dysfuction Blood dyscrasias
Dose and side effects of Baclofen?
5mg bd-tds
Max dose
100mg/24hrs
** Side-effects:**
GI upset
Hypotension
Dry mouth
Drowsiness, sedation, dizziness, confusion, muscular hypotonia
what are the two types of antidepressants used for chronic facial pain?
Tricyclic antidepressant’s or Selective serotonin reuptake inhibitors (SSRIs)
What are the types of TCA’s, the dose and side effects?
Amitriptyline
Nortriptyline
10mg on, increased to 70mg on as needed
Side-effects:
Sedation, dizziness, ataxia
Dry mouth, constipation, urinary retention, blurred vision
Cardiac arrhythmias
what are the main SSRI’s, dose and side effects?
Citalopram 20mg od
Max dose 60mg/24hrs
Side-effects:
- GI upset
- Hypersensitivity
- Generally well-tolerated and less sedating that the TCAs
What are the difficulties in managing chronic facial pain patients?
Difficulties explaining non organic pathology
Fear of missing organic disease
Overwhelmed by pain behaviour exhibited by patient.
Managing co existent organic pathology
How cna you predict the patients which are not going to respond well to treatment?
Defensive patients
Use of terms of endearment to report disease Excessive focus upon symptoms
Overt and hostile criticism of previous treatment History of repeated episodes of inadequate treatment
