Facial pains

Question 1

Trigeminal Neuralgia - definition

Answer 1

Trigeminal neuralgia (TN) is a facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve. It is characterised by some combination of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or a constant component of facial pain, without associated neurological deficit.

Question 2

Trigeminal Neuralgia - presentation

Answer 2

• RF: increased age and MS
• Short lasting (seconds), lancinating (electric shocks), paroxysms of pain precipitated by touch, eating, talking, wind, washing face and brushing teeth. No pain between episodes.
• Pain described as intense, sharp, superficial, stabbing or burning in quality.
• No relieving factors
• Allodynic trigger zones
• fearful of repeat attacks
• sometimes history of prior oropharyngeal or facial trauma (secondary trigeminal neuralgia)

Question 3

Types of Trigeminal Neuralgia

Answer 3

• Classic (CTN): typically unilateral pain

- Symptomatic: secondary to other cause, typically bilateral involvement

Question 4

Trigeminal neuralgia - investigations

Answer 4

Clinical Dx

Question 5

Trigeminal neuralgia - management

Answer 5

1st line: anticonvulsant (carbamazepine)
- med unresponsive: microvascular decompression (vascular loop separated from trigeminal nerve)
OR
ablative surgery (radiosurgery, balloon compression)

Question 6

Facial arthromyalgia (TMJ syndrome)

Answer 6

• Continuous, variable (not attacks)
• Dull, aching with infrequent sharp pains
• Eating may exacerbate
• Heat, relaxation/massaging relieves
• Muscular tenderness
• Anxiety/depression
• Evidence of bruxism (teeth grinding)

Question 7

Postherpetic neuralgia

Answer 7

neuropathic pain due to damage to a peripheral nerve caused by the reactivation of the varicella zoster virus (herpes zoster, also known as shingles)
Rx: 
Gabapentin
Amitryptiline
Tramadol
Oxycodone
Lignociane patch

Question 8

What is neuropathic pain?

Answer 8

• Pain caused by damage or disease affecting the somatosensory nervous system.
• May be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia).
• Continuous and/or episodic (paroxysmal - resemble stabbings or electric shocks)
• Include burning or coldness, “pins and needles” sensations, numbness and itching.

Question 9

Medications for neuropathic pain

Answer 9

amitriptyline – also for headaches and depression
duloxetine – also for bladder problems and depression
pregabalin and gabapentin – also for epilepsy, headaches or anxiety
capsaicin cream (specific part of body)
tramadol

Question 10

Atypical facial pain

Answer 10

• Continuous, static
• No known aetiology, no somatic findings (ie functional)
• Nothing provokes
• Nothing helps
• Anxiety/depression
• Fixation on symptoms

Question 11

Facial pains - differential dx

Answer 11

• Trigeminal neuralgia
• Facial arthromyalgia (TMJ syndrome)
• Post-herpetic neuralgia
• Atypical facial pain