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Facial Pain As A Cause Of HeadachesVictor A. Maquera, M.D.
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Table 1. Types Of Craniofacial Pain |
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Trigeminal Neuralgia is the most common type of neuralgic pain syndrome that occurs in the United States. The characteristics include a sharp, lancinating, "electrical" type of pain that lasts from seconds to minutes. This pain is usually triggered by irritation of one of the superficial branches of the trigeminal nerve and results in pain localized to one or more of its branches. A dull aching type of pain may be present in between attacks.1
The onset of this syndrome is usually in the sixth or seventh decades of life. Onset in a younger individual warrants an evaluation for multiple sclerosis. The natural history is unpredictable, with occasional infrequent remissions.
The mechanism is suspected to be a focal demylination of the affected branch of the trigeminal nerve, usually in association with an extra-axial vascular loop that compresses the nerve.2 Excluding other structural causes for this type of pain including dental pathology, intracranial tumors, aneurysms, tumors or demylinating disease makes the diagnosis.
Treatment can be characterized by medical treatment with various types of analgesics (Table 2). Nerve blocks with local anesthetics or alcohol may control the pain to varying degrees. In refractory cases, surgical decompression of the compressive vascular loop may be attempted by neurosurgeons skilled in cranial base surgery. In a minority of cases, these treatment modalities are unsuccessful and chronic pain management with long acting narcotics may be necessary.1
Table 2. Medications Useful In The Treatment Of Trigeminal Neuralgia |
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| Common |
Less Common * This is of limited use because of the potential for corneal |
This syndrome is similar to trigeminal neuralgia. The pain is sharp and paroxysmal, originating from the structures around the pharynx. The pain generally radiates from the pharynx to the ear. Swallowing, talking, chewing, yawning or laughing can trigger this particular form of neuralgia. Part of the pathway involving this pain syndrome involves the vagus nerve.3 Some sources classify this syndrome as "vagoglossopharyngeal neuralgia". As a result, this pain syndrome is the only one that may be associated with bradycardia or syncope.4
Diagnosis is made by eliciting the appropriate history. Other conditions such as demylinating disease, neoplasm, carcinomatous meningitis or peritonsillar absess can produce pain indistinguishable from this syndrome. Treatment is identical to the treatment outlined for trigeminal neuralgia. Infrequently, rhizotomy may be necessary.5
Occipital neuralgia is a chronic pain syndrome originating from irritation of the greater occipital nerve. The pain associated with this syndrome is localized to the distribution of the greater occipital nerve.6 This pain syndrome is frequently a cause of chronic daily headaches. Occipital neuralgia is commonly a result of spasm of the cervical paraspinal muscles.7
The diagnosis of occipital neuralgia is fairly simple. Palpation of the greater occipital nerve reproduces the pain syndrome. Paraspinal muscle spasm may also be appreciated. Cervical spine X-rays or MRI may disclose structural problems associated with spasm of the paraspinal muscles such as disc herniations, degenerative arthritis or spinal stenosis.6
Treatment is with the drugs noted in Table 2. Trigger point injections and/or nerve blocks composed of steroids and local anesthetics are frequently useful in the treatment of this pain syndrome7. Botulinum toxin may play a role in the treatment of this condition in the future. Other similar conditions, less commonly recognized, but treated identically are auriculo-temporal neuralgia and supra-orbital neuralgia.
Carotidynia is a chronic pain syndrome associated with pain and tenderness on palpation of the carotid arteries. This pain syndrome radiates from the carotid artery, up the neck to include pain in the ipsilateral face, ears, jaws and teeth. It can also radiate down the neck. This pain can also occur with displacement of the carotid artery by tumor, trauma or dissection.8 Diagnosis is made by palpation of the carotid artery and eliciting pain. Treatment is by utilizing the same drugs listed in Table 2.
Multiple sclerosis can cause a pain syndrome similar to trigeminal neuralgia and
glossopharyngeal neuralgia. The etiology appears to be demylination in the pons and
medulla. Clues that multiple sclerosis might be the cause of pain are "Lhermitte's
sign", an electrical sensation down the spine and extremities and the presence of
long tract signs such as the presence of "Babinski's sign" or focally increased
reflexes or focal weakness.9 Treatment is consis
tent with Table 2, with the addition of one of the beta-interferons or glatiramer acetate
if indicated.
Dental sources for pain can cause syndromes which are referred to the face, temporal area, jaw and neck. Appropriate evaluation and treatment by dentists or maxillofacial surgeons can assist in the diagnosis and treatment of these forms of pain.
REFERENCES
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