FACE PAIN CAUSES AND TREATMENT
FACE PAIN
Most common cause of facial pain is dental : triggered by hot ,cold or sweet foods.Exposure to cold repeatedly induces dental pain .Trigeminal neuralgia consist of paroxysmal ,electric shock-like episodes of pain in the distribution of trigeminal nerve : occipital neuralgia presents as lancinating occipital pain.
The face is richly supplied with pain-senstive structures - the teeth ,gums ,sinuses ,temporomandibular joints , jaw and eyes .Disease of these causes facial pain.Facial pain is also caused by specific neurological coditions. such as ,
Trigeminal neuralgia ,trigeminal nerve lesions and postherpetis neuralgia.
TRIGEMINAL NEURALGIA ( TIC DOULOUREUX )
Frequent ,excruciating paroxysms of pain in lips ,gums ,cheek ,or chin ( rarely in opthalmic division of fifth nerve ) lasting seconds to minuts .Typically presents in middle or old age.Pain is often stimulated at trigger points.Sensory deficit cannot be demonstrated.Must be distinguished from other forms of facial pain arising from diseases of jaw ,teeth ,or sinuses.Rare causes are herpes zoster or a tumor.Onset in young adulthood raises the possibility of multiple sclerosis.
TREATMENT
Carbamazepine is effective in 50 - 75% of cases .Begin at 100 mg single daily dose taken with food and advance by 100 mg every 1-2 days until substantial ( 50%) pain relief occurs.Most patients require 200 mg qid : doses > 1200 mg daily usually provide no additional benefit.Follow complete blood count for rare complication of agranulocytosis .
For nonresponders ,phenytoin ( 300 -400 mg qd ) or baclofen ( 5-20 mg tid -qid ) can be tried .When medications fail ,surgical lesions ( heat or glycerol injection ) can be effective : in some centers , microvascular decompression recommended in a tortuous blood vessel found in posterior fossa near trigeminal nerve.
For nonresponders ,phenytoin ( 300 -400 mg qd ) or baclofen ( 5-20 mg tid -qid ) can be tried .When medications fail ,surgical lesions ( heat or glycerol injection ) can be effective : in some centers , microvascular decompression recommended in a tortuous blood vessel found in posterior fossa near trigeminal nerve.
CLUSTER HEADACHE ( MIGRAINOUS NEURALGIA )
This condition ,distinct from migraine despite its name ,describes recurrent bouts of excruciating unilateral pain that wake the patients .Attacks cluster around one eye .It affects adults ,commencing in the third and fourth decades and is more common in men.Alcohol sometimes provokes an attack ,and also experimentally ,nitroglycerin .There are suggestions that there is a change in grey matter density on functional imaging in the posterior hypothalamus.The pain rises to a crescendo over half an hour and lasts for several hours.Vomiting occurs .One cheek and nostril feel congested .Transiet ipsilateral Horner's syndrome is common.
Despite very severe pain there are no serious sequelae.Attacks recur at intervals over several years but tend to disappear after 55.Analgesics are unhelpful.Triptans may abort an attack.Prophylactic migraine drugs are of little value.Lithium carbonate ( 400 - 1200 mg daily ) sometimes has a dramatic effect in preventing attacks: the drug level should be monitored .Inhalation of oxygen sometimes helps stop an attack.
PAROXYSMAL HEMICRANIA
Episodic paroxysmal hemicrania is a rare condition describing unilateral sudden brief ( < 20 minutes ) pain with characteristics of headaches.The pains may occur many times each day .Typically they respond to indomethacin.
ATYPICAL FACE PAIN
Facial pain for which no cause can be found is seen in the elderly ,mainly in women .It is believed to be a somatic equivalent of depression .Tricyclic antidepressants are sometimes helpful.
OTHER CAUSES OF FACE PAIN
Facial pain occurs in variants of migraine and in giant cell arteritis .
GIANT CELL ARTERITIS ( GCA , CRANIAL ARTERITIS ,TEMPORAL ARTERITIS )
This condition is a granulomatous arteritis of unknown aetiology occuring chiefly over the age of 60 .It affects extradural arteries .Other forms of arteritis ,such as systemic lupus erythematosus ( SLE ) and microscopic polyangitis ,can occasionally present with similar features .Giant cell arteritis is closely related to polymyalgia rheumatica and can coexist.
FACE PAIN IN GIANT CELL ARTERITIS
Pain in the face ,jaw and mouth is caused by inflammation of facial ,maxillary and lingual branches of the external carotid artery in Giant cell arteritis.Pain is characteristically worse on eating ( jaw claudication ) .Openin the mouth and protruding the tongue becomes difficult.A pain ful ischaemic tongue occurs rarely.
