Abstract
An overview of the anatomy, aetiology, assessment and management of facial pain.
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Key Points
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Trigeminal neuralgia.
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Glossopharyngeal neuralgia.
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Headache disorders including migraines, cluster headaches and temporal arteritis.
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Burning Mouth Syndrome.
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Atypical facial pain and atypical odontalgia.
Aetiology of Facial Pain
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Local—teeth/jaws.
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Psychogenic—psychosomatic/atypical facial pain/Burning mouth syndrome → associated anxiety/TMJ.
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Referred—Angina/oesophagus/neck/chest.
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Neurological—Trigeminal/MS/space-occupying lesion/herpes zoster.
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Vascular—Migraine/temporal arteritis/cluster headaches.
Trigeminal Neuralgia
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Disorder of cranial nerve V: intense paroxysmal pain with one or more divisions.
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3–6/100,000: more common in females—incidence and severity increase with age → Usually 50–70 years.
Causes
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Compression of trigeminal nerve root by artery in middle cranial fossa (pons): 80–90%, rarely by aneurysm/AV malformation.
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Nerve demyelination: suspect MS in younger patients.
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Others: CNS.
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Achondroplasia.
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CPA Lipoma/schwannoma/pituitary tumour/sarcoid.
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Charcot-Marie-Tooth.
Symptoms
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Paroxysmal pain: Intense, lancinating, burning pain “like electric shock”—lasts seconds/minutes.
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Frequency varies—may be multiple times, almost always unilateral.
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Many patients have trigger points—stimulated every day, with period remission and relapse, worsen overtime.
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Eating.
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Talking.
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Washing.
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Shaving.
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Toothbrushing.
Investigations
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Complete neurological examination, look for signs/symptoms of multiple sclerosis (multiple defects):
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Vision.
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Weakness.
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Limbs.
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MRI brain if:
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Atypical features.
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Patient age <50, look for intracranial lesions/MS.
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Consider microvascular decompression.
Management—Medical First Line Treatment
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Most effective anticonvulsants: carbamazepine 100 mg BD (up to 1600 mg in 3–4 divided doses), follow-up with wean after six months, early side effects decrease with time, must monitor FBC, U&Es and LFTs.
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Leucopenia.
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Rashes/Nausea and vomiting/dizziness/headaches/diplopia.
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Ox carbamazepine: induces hepatic enzymes to a less extent.
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Unlicensed use for trigeminal neuralgia.
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Usually 300 mg/BD up to 600 mg/daily.
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Usually 600 mg–2400 mg/divided doses daily.
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Review in facial pain clinic and wean eventually.
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Gabapentin/lamotrigine also used as second-line agent.
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Severe cases I.V. phenytoin in a crisis.
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Start with small initial dosages and then increase. A few patients may be unresponsive or unable to tolerate side effects. Consider surgery adjuvant with neurosurgical assessment.
Peripheral Procedures
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Cryotherapy/chemical destruction/radiotherapy ablation.
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Stereotactic (gamma knife).
Options:
Operative:
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Nerve blocks with alcohol/phenol—temporary relief (up to 2 years).
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Avulsion of the superior/inferior orbital nerves—prolonged pain relief.
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Fogarty balloon inflation—ganglion in Meckel’s cave (or glycerol injection).
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Radiofrequency thermocoagulation—site of facial tingling produced by electrical stimulation of needle inserted into trigeminal ganglion. When site of tingling corresponds to trigger spot, thermocoagulation produces analgesia of the appropriate area.
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Microvascular decompression—exploration of cerebellopontine angle (CPA) reveals blood vessel in contact with trigeminal nerve root—Separation using non absorbable (Teflon) sponge can produce relief in symptoms.
Risks
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Permanent.
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Paraesthesia/anaesthesia.
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Dolorosa (severe continuous pain within distribution of nerve).
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Pain relief = 80–85% remain pain free for 5 years.
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Young = microvascular decompression (MVD).
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Elderly/frail = interventions.
Surgery Risks:
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Damage to cranial nerves V, VII, VIII.
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Vascular damage.
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Post-operative weakness.
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If sensory loss to cornea = risk of scarring, have eyelid shut until able to test corneal reflex—need special glasses with sides.
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Can get relapse after MVD—consider re-operation as vessels move or material dislodged.
Glossopharyngeal Neuralgia
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Rare—similar to trigeminal = pain felt at base of the tongue and fauces on one side.
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TN:GN 100:1.
Symptoms
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Poorly localised—affects tonsils, tongue base, ear/and intra-auricular area.
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Patient often point to behind angle of mandible—symptoms often treated as TMJD.
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Trigger point difficult to identify = yawning/swallowing.
Investigations
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Topical LA to ipsilateral tonsils/pharynx—immediate relieves symptoms, but short acting *Diagnostic.
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MRI—Space-occupying lesion in cranial cavity or jugular foramen/MS.
Management
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Medical similar to management of trigeminal.
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Surgical—MVD.
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75% works.
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Risks—morbidity/mortality.
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Headaches: many causes.
Migraine
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Primary recurrent headache disorder.
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More common in females.
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Usually commonest in adolescence.
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Termed ‘hemicrania’ as it affects half of the head.
Cause
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Possible relationship to abnormal 5-HT (serotonin) activity—leading to initial vasoconstriction of portions of cerebral arteries, followed by compulsory vasodilation, with cerebral oedema and pain.
Precipitant
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Hormonal factors including Oral Contraceptive Pill (OCP).
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Diet—chocolate/bananas, stress, sleep deprivation, bright/flashing lights.
May Have Preceding Aura
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Visual hallucination—flashing lights/decrease in color, visual disturbance.
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Motor—temporary motor palsy.
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Speech—aphasia.
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Severe unilateral headache—initially poorly localised, becomes localised to temporal/frontal/orbital region.
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Photophobia/nausea/vomiting.
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Attacks decrease with age—may totally resolve.
Management
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Acute attacks: Triptan (5-HT antagonist) plus NSAID/paracetamol.
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Prophylaxis: Topiramate or propranolol, acupuncture.
Cluster Headaches
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Exquisite pain of midface/upper face—centred around eyes.
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Attacks occur in temporal groups/clusters—extended periods of remission between attacks.
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Often positive FH=Family history.
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80% are smokers.
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30–40 years.
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Less common than migraines.
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Male:Female 6:1.
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1:10,000 males/year.
Cause
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Unknown, allergic basis with mast cell release and vasodilatation.
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Associated with sleep apnoea, and low oxygen saturation.
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Alcohol, cocaine, GTN spray.
Symptoms
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Severe unilateral episodes of burning/lancinating pain in and around the orbit/frontal/temporal.
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Abrupt onset—lasts for 15 min to 3 h—often wakes patient at night.
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Begins same time every day (alarm clock headache—may have multiple episodes every day).
May be Associated with Autonomic Symptoms
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Conjunctival vessel congestion.
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Eye watering.
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Nasal stiffness.
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Facial Flushing.
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Diagnosis.
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Clinical/MRI.
Management
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Acute attacks.
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Oxygen may abort attacks and its effectiveness diagnostic.
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Subcutaneous triptan.
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Prophylaxis.
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Verapamil drug of choice.
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Nifedipine.
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Lithium.
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Ergotamine.
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*Distinguish from chronic paroxysmal hemicrania—respond to indomethacin.
Giant Cell Arteritis
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Multifocal vascular affecting the cranial arteries.
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Unknown aetiology.
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Systemic vascular—large/medium vessels especially branches external carotid.
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Females > Males.
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Average onset—70 years.
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Related to polymyalgia rheumatica (PMR).
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Genetic predisposition possible.
Symptoms
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Unilateral headache—initial burning—throbbing.
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Usually temporal/or occipital artery.
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Lingual/facial/maxillary arteries may get involved leading to claudication on eating/drinking.
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Affected vessels feel hard/tender.
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Tongue ischaemia if lingual artery.
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TIA/CVA.
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Left untreated.
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25% develop visual problems.
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Due to central retinal artery involvement—which may be bilateral—loss vision.
Diagnosis
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Increased ESR 60–100 (although can be normal), normocytic normochromic anaemia.
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Temporal artery biopsy with granuloma formation.
Management
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Prednisolone >50 mg daily.
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I.V. methylprednisolone first if visual loss.
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Urgent ophthalmological assessment.
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Consider rheumatology referral.
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Decrease steroid with resolution of headache—ESR may take month/years to normalise.
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PPI.
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Osteoporosis cover—bisphosphonates.
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Calcium/Vitamin D.
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Aspirin (decrease CVA).
Burning Mouth Syndrome
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Burning sensation of oral mucosa (usually tongue—glossopyrosis) in absence of any pathology.
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Common 5 in 100,000—much higher middle aged and elderly.
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Female:Male 16:1.
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Age >50 years.
Aetiology
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Unknown.
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Psychogenic.
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Increased in anxiety/depression/stress.
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Obsession.
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Cancerphobia.
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First exclude organic cause of burning.
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Local.
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Xerostomia/chronic mouth breathing/mechanical trauma/referred pain/trigeminal neuralgia/atypical facial or neuralgia/angioedema/candidiasis/TMJD/submucous fibrosis/trauma lingual nerve.
Systemic
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B vitamins, folate, zinc, iron.
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Diabetes mellitus / GORD/ hypothyroidism/ oestrogen deficiency/ Parkinson’s / AIDS.
Symptoms
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Dry mouth/altered or bad taste.
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Burning sensation affecting tongue and anterior palate, less common in lips.
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Aggravated by certain food—usually bilateral.
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Does not wake patient, but often present on waking.
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Normal examination.
Investigations
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FBC/haematinics/swab candida—all normal.
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Tricyclic antidepressants—side effects.
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Arrythmias/heart block.
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Postural hypotension/tachycardia.
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ECG changes.
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Dry mouth/blurred vision/constipation/urinary retention.
Management
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Reassurance.
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Avoid stimulating factors.
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Cochrane review: Amitriptyline 10 mg daily (max 75 mg daily titrated/Clonazepam 1 mg TDS mouthwash.
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Tricyclic antidepressant—same patients respond.
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2nd line: Pregabalin 150 mg divided doses daily/75 mg BD.
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Tricyclic antidepressants: nortriptyline: 10–25 mg once at night (maximum 75 mg once at night); less sedative effects than amitriptyline.
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CBT: shown in RCTs to help patients manage symptoms—as medical management often disappointing.
Atypical Facial Pain
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Diagnosis of exclusion.
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Constant chronic dull ache.
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Most common in females—middle age/elderly.
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Can get intermittent/severe episodes, may be bilateral.
Clinical
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Often difficult for patient to describe—deep constant ache or burning.
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No anatomical bundles—cross midline moves to different sites.
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Maxilla > mandible.
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Does not stop sleeping, but may awaken with pain.
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Often exacerbated/initiated by dental treatment.
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Often have other complaints: IBS/TMJD/back pain/neck pain/dry mouth—diagnosis from trigeminal neuralgia is difficult (lack of trigger, vague distribution).
Investigations
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MRI/Bloods/Biopsy—nerve.
Management
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Tricyclic antidepressant—some effect on symptoms—no adequate RCT to show this.
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30% respond gabapentin. Dose regime
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(a)
Day 1: 300 mg/OD
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(b)
Day 2: 300 mg/BD
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(c)
Day 3: 300 mg/TDS
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(a)
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Pain team/CBT.
Atypical Odontalgia
Pain tooth/site of extraction—sharp/aching/throbbing, burning—exclude pathology
Management Includes:
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Topical capsaicin—some benefit, need for several weeks.
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EMLA.
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Tricyclic antidepressant.
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Gabapentin.
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Ahmed, A., Farook, S., Perry, M. (2023). Facial Pain. In: Oral and Maxillofacial Surgery. Springer, Cham. https://doi.org/10.1007/978-3-031-25473-4_4
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DOI: https://doi.org/10.1007/978-3-031-25473-4_4
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