Facial pain and the second edition of the International Classification of Headache Disorders

BACKGROUND: Recurrent or chronic facial pain may be a diagnostic challenge. Applying the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) leaves a considerable number of patients unclassifiable. OBJECTIVE: The aim of this study was to establish and evaluate revised criteria of trigeminal neuralgia and persistent idiopathic facial pain. METHODS: Based on the diagnostic value of 12 clinical features of trigeminal neuralgia and 15 features of persistent idiopathic facial in 97 patients referred for facial pain to a neurological tertiary care centre we established revised criteria for persistent idiopathic facial pain and additional criteria for probable trigeminal neuralgia and probable idiopathic facial pain. RESULTS: Applying the newly proposed criteria reduced the number of patients with facial pain not classifiable by more than 50%. The new criteria improved the sensitivity, particularly in idiopathic facial pain and did not cause a relevant decrease in specificity compared to ICHD-II. CONCLUSION: This study suggests that amendments to the ICHD-II criteria improve the diagnostic classification of facial pain.     

Pain Remapping in Migraine: A Novel Characteristic Following Trigeminal Nerve Injury

(Headache 2010;50:669‐674) The location of pain during the headache phase of migraine varies between individuals as well as between attacks in some individuals. We have observed a “remapping” or a change in the location of migraine pain following injury to the trigeminal system that is a novel characteristic to migraine and has not been described in other trigeminal pain syndromes of the head, neck, and face. Recognition of this clinical feature implies that the pathophysiology of migraine is impressionable and may be why diagnosis and treatment are often delayed.     

Lung cancer presenting with unilateral facial pain: remission after laryngeal nerve palsy

A 39-year-old woman presented with a 2-month history of intractable, left-sided facial pain. A CT scan of the thorax disclosed a large lung mass surrounding supra-aortic vessels and hilus. The symptoms underwent a rapid and spontaneous remission after laryngeal nerve palsy with dysphonia developed. Referred facial pain secondary to the compression of the vagus nerve can rarely be the first manifestation of an underlying lung cancer. All cases of unexplained unilateral facial pain should be investigated for a mediastinal pathology, especially in smoker subjects.     

Facial Pain as a Symptom of Nonmetastatic Lung Cancer

Patients with nonmetastatic lung cancer may rarely experience facial pain as a presenting symptom, during the course of the disease or upon recurrence of the disease. This study reviews a 10-year experience at Mayo Clinic. The aim of this study was to (1) further characterize the clinical features of facial pain as a symptom of nonmetastatic lung cancer, and (2) assist clinicians in recognizing this association. Ten cases were identified. All patients complained of severe, aching, facial pain typically aural-temporal in location, ipsilateral to the lung cancer. Six of the 10 cases involved the left side. Recent weight loss was present in 7 of 10 patients, with an elevated sedimentation rate in 6. Digital clubbing was documented in three. Neurologic examinations and neuroimaging were normal in all patients. Lumbar puncture, when performed, was normal. Facial pain preceded the diagnosis of lung cancer by 1 to 24 months. In three patients, facial pain was the initial symptom of tumor recurrence. Four of the 10 tumors were adenocarcinoma; radiation with or without chemotherapyappears to be the treatment of choice for the facial pain. The presumed mechanism is local invasion of the vagus nerve. In suspected cases, a chest x-ray and chest CT are indicated.     

Cutaneous sensory stimulation leading to facial flushing and release of calcitonin gene-related peptide

A patient is described with a 17-year history of intractable left-sided facial pain. The pain occurred daily in 5 sec spasms to a maximum of one every 2-3 min and was restricted to the left upper face. It was associated with rhinorrhoea on the left and often with ipsilateral facial flushing. Conventional therapy, including carbamazepine, baclofen and three posterior fossa explorations, had not provided lasting relief. Local facial stimulation by tapping a painful trigger point led to both pain and flushing of the face ipsilaterally. During this flushing, blood was collected and assayed using sensitive radioimmunoassays for several neuropeptides (neuropeptide Y, substance P, vasoactive intestinal polypeptide and calcitonin gene-related peptide). A marked (119%) increase in calcitonin gene-related peptide was noted in the external jugular vein blood ipsilaterally during the flushing with no change in the other peptides measured. To quantitate the effect of calcitonin gene-related peptide on human extracranial vessels, standard pharmacological procedures were used to examine the potency of the peptide as a vasodilator of human facial artery. The IC50 of calcitonin gene-related peptide for the prostaglandin F2 alpha-precontracted human facial artery was 10(-9) mol/l. The relevance of these observations to the clinical problem of migraine is considered.     

Cervical sympathetic neuralgia arising from a schwannoma

We describe an unusual case of neuropathic pain of the left face and shoulder accompanied by ipsilateral hyperhidrosis caused by a schwannoma of the cervical sympathetic chain. Additional signs of associated sympathetic hyperactivity included left-sided lacrimation, conjunctival injection, and nasal congestion. Autonomic testing demonstrated signs of increased vasomotor and sudomotor activity in the left palm. The pain was refractory to analgesic and antimigraine medications but resolved following surgical resection of the T2 schwannoma.     

Somatosensory abnormalities in atypical odontalgia: A case-control study

Somatosensory function in patients with persistent idiopathic types of orofacial pain like atypical odontalgia (AO) is not well described. This study tested the hypothesis that AO patients have significantly more somatosensory abnormalities than age- and sex-matched controls. Forty-six AO patients and 35 controls participated. Inclusion criteria for AO were pain in a region where a tooth had been endodontically or surgically treated, persistent pain >6 months, and lack of clinical and radiological findings. The examination included qualitative tests and a battery of intraoral quantitative sensory testing (QST). Most AO patients (85%) had qualitative somatosensory abnormality compared with few controls (14%). The most common qualitative abnormalities in AO patients were found with pin-prick 67.4%, cold 47.8%, and touch 46.5% compared with 11.4%, 8.6%, and 2.9%, respectively, in the control group (P<0.001). Between-group differences were seen for many intraoral QST: mechanical detection threshold, mechanical pain threshold (pinprick), dynamic mechanical allodynia (brush), dynamic mechanical allodynia (vibration), wind-up ratio, and pressure pain threshold (P<0.01). In the trigeminal area, between-group differences in thermal thresholds were nonsignificant while differences in cold detection at the thenar eminence were significant. Individual somatosensory profiles revealed complex patterns with hyper- and hyposensitivity to intraoral QST. Between-group differences in pressure pain thresholds (P<0.02) were observed at the thenar eminence. In conclusion, significant abnormalities in intraoral somatosensory function were observed in AO, which may reflect peripheral and central sensitization of trigeminal pathways. More generalized sensitization of the nociceptive system may also be part of AO pathophysiology.     

Trigeminal Neuralgic-Type Pain and Vascular-Type Headache Due to Gustatory Stimulus

We present a case of facial pain associated with sweet stimulus. An immediate, electriclike, short, unilateral pain was evoked by strong sweet gustatory stimulation. This was followed 6 to 8 hours later by a bilateral severe headache associated with bilateral tearing, rhinorrhea, periorbital swelling, flushing, and photophobia that lasted up to 2 days. The immediate pain that was experimentally induced with 2.5 grams of sucrose placed on the tongue could be abolished with carbamazepine. However, carbamazepine did not prevent the headache complex that appeared 6 to 8 hours later. Conversely, a trial with indomethacin abolished the late-onset headache, but not the immediate neuralgic-type pain. The independent nature of these pains suggests different pathophysiological mechanisms which are discussed.     

Using facial expressions to assess musculoskeletal pain in older persons.

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.     

Efficacy of Meclofenamate Sodium versus Placebo in Headache and Craniofacial Pain

SYNOPSIS
Twenty patients were enrolled in a double-blind, placebo- controlled crossover study of meclofenomate sodium in headache and craniofacial pain. There were four observation periods of 15 days each: Period I was a wash-out period. In period 2, subjects were randomly assigned to a 15-day regimen of taking two capsules a day of 100mg meclofenamate sodium (group 1) or placebo (group 2). In period 3, group I was switched to placebo and group 2 to meclofenamate sodium for the next 15 days. Lastly, the patients took no medication for a further 15 days (period 4). A thermographic record of the craniofacial and neck areas was taken at the end of periods 1 and 4. A record of the pressure threshold and tissue compliance at different sites of the craniofacial, neck and shoulder areas was taken at the end of each period. During the trial, number and duration of painful events were recorded daily by the patients, and the level of pain evaluated on a visual analog scale. Mean data were analyzed for significant difference by ANOVA and paired t-test. During the meclofenamate sodium period, there was a significant decrease of days with painful events compared to the wash-out period in group I and compared to the placebo period in group 2. In the majority of patients, the meclofenamate sodium period scored lowest or second-lowest after the follow-up period in mean pain intensity. Data for pressure threshold, although not significant, were indicative of a possible increase during and after intake of meclofenamate sodium. An improvement of thermal symmetry was recorded at the second thermogram in a majority of patients. It is concluded that meclofenamate sodium showed a consistent analgesic effect in our patients, compared to the placebo.     

The Tooth,the Whole Tooth,and Nothing But the Tooth: Can Dental Pain Ever Be the Sole Presenting Symptom of a Myocardial Infarction? A Systematic Review

Background

Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, should emergency physicians consider the possibility of myocardial infarction in patients who present solely with dental pain?

Objective

This is a systematic review of the literature investigating the incidence of jaw, tooth, or facial pain as the sole symptom of cardiac ischemia.

Methods

Studies investigating jaw, tooth, or facial pain of cardiac origin were identified using the PubMed database. All English studies in which cardiac pain originated in the face, teeth, or jaw were screened for inclusion. Data were abstracted from each study utilizing a structured review process, and rated for methodological quality.

Results

Eighteen studies met study criteria: 16 were case reports, and the remaining 2 were prospective cohort studies. After quality assessment and categorization, nine reports were categorized as weak, eight moderate, and one strong methodological quality.

Conclusion

Cardiac ischemia may present in no anatomic location other than face or jaw. However, despite frequent claims in the literature to the contrary, the lack of methodological quality of the studies investigated impedes a firm conclusion of face, jaw, or tooth pain as the only symptom of cardiac insufficiency.     

Atypical odontalgia: a review of the literature

OBJECTIVE: To review previous reports of cases of atypical odontalgia to examine its epidemiological and clinical characteristics and to explore the etiology and pathophysiology of the disease. BACKGROUND: Atypical odontalgia is one of many painful conditions that affect the oral cavity and is often overlooked in the differential diagnosis. METHODS: A search of the literature was performed for all cases of atypical odontalgia reported from 1966 to the present. RESULTS: The typical clinical presentation of atypical odontalgia that has been reported involves pain in a tooth in the absence of any sign of pathology; the pain may spread to areas of the face, neck, and shoulder. The existing literature suggests that this condition occurs in 3% to 6% of the patients who undergo endodontic treatment, with high female preponderance and a concentration of cases in the fourth decade of life. Deafferentation seems to be the most likely mechanism to initiate the pain, but psychological factors, alteration of neural mechanisms, and even an idiopathic mechanism have been implicated. Not all reported cases were preceded by trauma to the teeth or gums. The treatment of choice is a tricyclic antidepressant, alone or in combination with a phenothiazine. The outcome is usually fair, with many patients obtaining complete relief from pain. Especially in the absence of overt pathology, particular attention should be paid to avoiding any unnecessary and potentially dangerous dental intervention on the teeth. CONCLUSION: Atypical odontalgia is surprisingly common, of uncertain origin, and potentially treatable.     

Effect of local anesthesia on atypical odontalgia--a randomized controlled trial

The aim of the study was to evaluate the analgesic effect of lidocaine in a double-blind, controlled multi-center study on patients with atypical odontalgia (AO)--a possible orofacial neuropathic pain condition. Thirty-five consecutive AO patients (range 31-81 years) with a mean pain duration of 7.2 years (range 1-30 years) were recruited from four different orofacial pain clinics in Sweden. In a randomized cross-over design, 1.5 ml local anesthesia (20mg/ml lidocaine and 12.5 microg/ml adrenaline) or 1.5 ml saline (9 mg/ml NaCl solution) (placebo) was injected to block the painful area. The VAS pain scores showed an overall effect of time (ANOVA: P<0.001) and treatment (ANOVA: P=0.018) with a significant interaction between the factors (ANOVA: P<0.001). Overall, VAS pain relief was significantly greater at 15-120 min following the lidocaine injections compared to the placebo injections (Tukey: P<0.05). All patients demonstrated significant disturbances in somatosensory function on the painful side compared to the non-painful side as revealed by quantitative sensory tests, however, only one significant inverse correlation was found between percentage pain relief and the magnitude of brush-evoked allodynia (Spearman: P<0.01). In conclusion, AO patients experienced significant, but not complete, pain relief from administration of local anesthetics compared with placebo. The findings indicate that the spontaneous pain in AO patients only to some extent is dependent on peripheral afferent inputs and that sensitization of higher order neurons may be involved in the pathophysiology of AO.     

Facial pain in a neurological tertiary care centre--evaluation of the International Classification of Headache Disorders

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.     

Herpes Zoster Ophthalmicus Mimicking Carotid Artery Dissection: A Case Report

Herpes zoster is a common viral illness presenting with vesicular eruptions which are usually preceded by pain, erythema, and tenderness in a dermatomal distribution. The ophthalmic division of the trigeminal nerve is commonly involved (herpes zoster ophthalmicus). Early diagnosis before eruption of vesicles can be difficult and symptoms may be confused with other neurologic disorders. We present a patient with herpes zoster ophthalmicus who presented with face and neck pain associated with visual symptoms mimicking carotid artery dissection. Atypical presentation and benefits of early antiviral treatment are discussed.     

Familial trigeminal neuralgia: case reports and review of the literature

The paroxysmal facial pain of trigeminal neuralgia is usually idiopathic, but familial cases have been described. We describe a family with apparent autosomal dominant transmission of trigeminal neuralgia. Our cases and a review of the literature suggest that the etiology of trigeminal neuralgia may be vascular compression of the fifth cranial nerve. Autosomal dominant vascular and epileptic disorders are reviewed, and possible relationships to familial trigeminal neuralgia are considered.     

Post-Traumatic External Nasal Pain Syndrome (a Trigeminal Based Pain Disorder)

Little has been written about persistent external nasal pain after injury to the nose in the neurologic or headache literature. In clinical practice, this can be a disabling and treatment refractory condition. The external portion of the nose is highly innervated by branches of the ophthalmic and maxillary divisions of the trigeminal nerve including the nasociliary nerve, external nasal nerve, infratrochlear nerve, anterior ethmoidal nerve, and infraorbital nerve. As these nerves are located on the external portion of the nose just deep enough to the skin they can be easily traumatized with any impact to the nose.
Four patients with what is termed the post-traumatic external nasal pain syndrome are reported in this paper, describing the clinical presentation of the disorder and providing treatment options. Post-traumatic external nasal pain syndrome appears to be a novel form of trigeminal-based pain not previously reported in the neurologic literature.     

Migraine with isolated facial pain: a diagnostic challenge

We present a series of seven migraine patients with typical features of a migraine attack without aura, but atypical pain localization in the face in one or both of the lower two distributions of the trigeminal nerve (V2 and V3). All of them responded well to triptans. Three patients responded to preventive treatment for migraine with beta-blockers (n = 2) or valproic acid (n = 1). These cases underline the heterogenic clinical presentation of migraine, which is sometimes difficult to diagnose even for headache specialists, and broaden the pathophysiological understanding of trigeminal nociceptive processing in migraine in the light of neuronal plasticity.     

Painful Trigeminal Neuropathy: Clinical and Pharmacological Observations

A 74-year-old woman had a 5-year history of constant burning pain and numbness of the central face of subacute onset. The central region of the face, oral cavity, and nose lacked all sensation. Corneal reflexes and the jaw jerk were absent. Blood tests, rectal biopsy, neurodiagnostic studies, and surgical exploration of the trigeminal nerve were normal. Blink reflexes were absent. Facial nerve motor latencies and EMG of the facial and masseter muscles were normal. Responses to the thermoregulatory sweat test, intradermal histamine, and simulated diving wore present. Oral administration of 500 mg dopa aggravated her pain and produced transient hypalgesia in the C2 through C5 dermatomes. Infraorbital nerve biopsy demonstrated loss of large myelinated fibers.
In conclusion: (1) Only the central region of the face is enclusively supplied by the trigeminal nerves. (2) Somato-autonomic reflexes coupled with electrophysiological studies Iocalized the lesion to the large fibers. (3) Large fiber loss and central brain stem reorganization may explain the burning pain. (4) Dopamine may modulate trigeminal nociception.