Facial Pain & Atypical Facial Pain
Unrelenting pain in the mouth or face is a frequent complaint in a pain management office. Paradoxically, very few are equipped to treat it effectively. The most common cause is usually some kind of dental problem, and is therefore easily treatable [1]. If, however, this has been ruled out and pain persists, you may be suffering from one of the chronic pain syndromes that falls under the broad diagnosis of facial pain.
The term “facial pain” is used to describe a variety of chronic pain syndromes such as headaches, trigeminal neuralgia, migraines, occipital neuralgia as well as many others. When the symptoms of pain do not meet certain criteria for a particular diagnosis, it may be given the term – atypical facial pain.
Facial pain can be felt as a pressure under the cheeks or eyes, or a sharp stabbing pain in areas of the face. Patients also describe a burning feeling under the skin, a throbbing and unabating headache, or a deep dull ache [2]. The patient’s description of how the pain feels along with the region effected can provide the physician with clues as to the underlying syndrome.
Facial pain is extremely complex and poorly understood. Current treatments are limited to oral medications which generally ineffective leaving those suffering from facial pain constantly searching for anything new that will help. The doctors at the Ainsworth Institute are amongst a handful of physicians across the country trained to perform select procedures to treat facial pain at the source, and in some cases, eliminate it altogether.
What is Facial Pain?
As mentioned above, facial pain is common, but because of the complex anatomy and specialized innervation of the head, presents a myriad of possible underlying causes.
Face and mouth pain disorders are diagnosed according to the standards published in the International Classification of Headache Disorders (ICHD-2) and are broken into three types[2]:
1) Primary Headaches
2) Secondary Headaches
3) Cranial Neuralgias, Central & Primary Facial Pain and other Headache Disorders
From a pain management perspective, we are concerned with patients exhibiting symptoms described in two subclassifications of types 2 and 3. They are headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures, and cranial neuralgias and central causes of facial pain [3].
Cranial Neuralgias
Facial Pain Categories
Each of the 3 types above is further broken down into several categories and then further divided into several subcategories. Type 1 (Primary Headaches) has 4 categories and Type 2 (Secondary Headaches) has 8 categories.
Type 3 (Cranial Neuralgias, Central & Primary Facial Pain and other Headache Disorders) is broken down into 2 categories (or categories 13 & 14).
Category 13
13.1 Trigeminal Neuralgia
13.2 Glossopharyngeal Neuralgia
13.8 Occpital Neuralgia
13.12 Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesions
13.15 Head or facial pain attributed to herpes zoster (postherpetic neuralgia)
13.18 Central Causes of facial pain (anesthesia dolorous, central post stroke pain, facial pain attributed to multiple sclerosis, persistent idiopathic facial pain, burning mouth syndrome)
Category 14
No subcategories
The Trigeminal Nerve
Advancing research has increasingly implicated the trigeminal nerve, and the entire trigeminal complex, in almost all known facial pain. The three branches of the trigeminal nerve (Ophthalmic, the Maxillary, and the Mandibular) can be responsible for transmitting the pain. The Ganglion (root where the 3 branches come together to enter the brain) can be responsible for perpetuating pain. The whole trigeminal system itself can also be responsible for spreading pain to other nerves.
The trigeminal nerve is the fifth (V) cranial nerve. Since sensation and pain from all these disorders are relayed to the brain via the cranial nerves, it’s a good idea to take a closer look at this system.
The Anatomy of the Cranial Nerves
I – Olfactory nerve. Carries your sense of smell.
II – Optic nerve. Attaches to the eye and enables you to see.
III, IV,VI – Oculomotor nerve, Trochlear nerve and Abducens nerve, respectively. These three nerves control eye movement.
V – Trigeminal nerve. Sensation on the skin of the face, also controls chewing.
VII – Facial nerve. Controls facial expression.
VIII – Vestibulocochlear nerve. Controls hearing and balance.
IX – Glossopharyngeal nerve. Controls feeling in the mouth, taste, and salivation.
X – Vagus nerve. Supplies motor parasympathetic fibers to organs.
XI – Accessory nerve. Shoulder and head movement.
XII – Hypoglossal nerve. Controls tongue movement.
Damage to any of the cranial nerves can cause a host of conditions and disorders. As mentioned above, though, facial pain is very frequently centered around the trigeminal nerve. Why this is the case, and the mechanism itself is still not fully understood.
Trigeminal neuralgia is an extremely painful neuropathic disorder of the trigeminal nerve. In addition, the trigeminal ganglion can influence the occipital nerves of the upper spine to cause occipital neuralgia, a condition which causes chronic pain in the upper neck and back of the head.
Throbbing headache
Migraine
Pressure under the cheeks or eyes
Sharp, lancinating pain in the face
Burning of the face and/or mouth [4]
Deep, dull ache
Pain caused by hot or cold food/liquids [5]
If trigeminal neuralgia is the cause patients tend to experience sudden and intense facial pain that lasts anywhere from a few minutes to several hours [6]. These attacks repeat themselves sometimes only with very short periods of remission. The pain of trigeminal neuralgia can become so severe, and the render an area of the face so sensitive, that some everyday activities like washing and shaving become impossible.
If occipital neuralgia is the culprit, patients usually develop a headache on one side that begins in the upper neck and travels over the top of the head, sometimes all the way to behind the eye. It is typically described as a sharp or shooting pain. Additionally, patients experiencing a pain behind the eye may also experience blurred vision.
Because of the complex anatomy and specialized innervation of the cranium, facial pain can be caused by a host of disorders.
Dental – Pulpitus, periodontal disease, gingivitis, disorders of the mandible and maxilla, disorders of the salivary gland.
Disorders of the eye – When not caused by obvious ocular symptoms, some underlying facial pain disorders can manifest with intense eye pain: cluster headache, paroxysmal hemicrania, trigeminal neuralgia, and sphenopalatine neuralgia [7].
Disorders of the ear – As with ocular pain, in the absence of obvious otological reasons facial pain originating in the ear can be caused by trigeminal nerve referred pain, glossopharyngeal nerve referred pain, Vagus nerve referred pain, and spinal nerves C2 and C3 referred pain [8],[9].
Disorders of the nose – Rhinosinusitus.
Temporomadibular disorders
Cranial Neuralgias – Trigeminal neuralgia, neuropathic facial pain, CRPS.
Your pain management doctor must first understand the history and quality of your present facial pain. He/she will ask you about the intensity, duration, and your need for medication. They should also want to know how much the pain has interfered with your lifestyle, and if you can remember events that may have triggered or aggravated the pain in the past.
The doctor will then need to ascertain your complete medical history and conduct a comprehensive physical examination of your head and neck. Further examinations can include evaluations of the trigeminal and facial nerves, as well as the upper cervical nerves, evaluation of muscle function of in the face and neck, examination of the temporomadibular joint, and examination of your mouth. If needed, CT scan, MRI or blood tests may be required.
IV Infusion Therapy – An increasingly popular procedure for treating a variety of pain syndromes, as well as depression and anxiety. Patients are hooked up to an IV and special medications are administered intravenously. The infusions can take as little as 30 minutes to complete and is typically covered by insurance.
Medical Marijuana – Cannabis has many medical qualities, one being its ability to act as a pain reliever. The evidence on medical marijuana for pain is very limited right now, even more so for facial pain, however many patients have reported substantial improvements in the frequency of their headaches as well as a decrease in intensity with this treatment.
Botox Injections – Everyone has heard of Botox for wrinkles, but what you may not know is it is extremely effective for treating headaches and facial pain. Botulinum Toxin (Botox) is injected into the muscles of the scalp to paralyze them thus releasing excess tension on the skull. When using it for headaches – it’s covered by insurance, even Medicare!
Sphenopalatine Ganglion Block – The sphenopalatine ganglion is a small organ no bigger than a piece of corn that is buried inside the skull. Amongst other things, it is responsible to conveying pain from the face into the brain. By applying a small amount of local anesthetic onto it, one can effectively stop pain signals from reaching the brain. If the block is successful, you doctor may recommend RFA to provide long lasting pain relief. This procedure is quite effective for a variety of types of facial pain – meaning even if the exact diagnosis is unknown or just unclear, it can still work!
Occipital Nerve Block – The occipital nerve runs along the back of the skull is responsible for a particular type of facial pain called – Occipital Neuralgia. Using fluoroscopic guidance, your doctor will injected a small amount of a local anesthetic called Bupivacaine. This will prevent the occipital nerve from transmitting pain signals. RFA can also be applied to the occipital nerve to provide longer lasting pain relief.
Gasserian Ganglion Block – The gasserian ganglion (better known as the trigeminal ganglion) is the meeting point for the 3 branches of the trigeminal nerve (the 5th Cranial Nerve). This ganglion has been implicated in a variety of facial pain syndromes as well as the dreaded Trigeminal Neuralgia. Using X-ray imaging, local anesthetic is injected onto the ganglion, blocking it from sending pain signals to the brain. In cases where the relief is only temporary, RFA may be the next step.
Stellate Ganglion Block – The stellate ganglion is an important part of the sympathetic nervous system and is well-known for its role in transmitting pain. A small amount of a special long-acting local anesthetic called Bupivacaine is injected near the ganglion using Ultrasound-Guidance to stop the pain signals from reaching the brain.
Neurolysis & Ablation – In cases where an injection provides only temporary relief, neurolysis or neuroablation can be utilized to increase the duration. There are several different methods that can be used:
- Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve or plexus, preventing the transmission of pain.
- Cryoablation – Similar to RFA, however cold temperatures are applied to the area instead of radio waves.
- Chemodenervation – The premise is the same as cryoablation and RFA in that the goal is to prevent a nerve or plexus from transmitting pain; rather than applying mechanical stress to the nerve through radiowaves or cold temperatures, small amounts of either alcohol or phenol are injected to block the nerve’s ability to transmit a signal.
Spinal Cord Stimulation (SCS) – This is a commonly performed procedure for a variety of pain syndromes. SCS utilizes technology similar to that of cardiac pacemakers whereby small electrodes are placed into the epidural space near the spinal cord. These electrodes will produce a small electrical current over the spinal cord that interfere with pain signals. In the case of facial pain, the leads are placed in the neck which stimulate nerves from the back of the head as well as the face.
Peripheral Nerve Stimulation – The premise is similar to SCS but rather the leads are placed under the skin in the area of the pain. The leads are extremely thin and are totally unnoticeable. Those suffering with pain in the back of the head (i.e. occipital neuralgia) would have 2 thin leads inserted under the scalp. Those with severe pain in the forehead or behind the eyes, the leads would be placed under the skin in the exact region of the pain from behind the hairline making it completely scarless.
Medication Management & Pharmacologic Therapy: Medications are typically the first treatment modalities tried, but rarely the most effective – NSAIDs, Opioids (some preference of kappa agonists in females), Antidepressants, Anticonvulsants, Muscle relaxants (tizanidine or baclofen).
The Ainsworth Institute is Here to Help
The doctors at the Ainsworth Institute of Pain Management specialize in managing and treating Facial Pain. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.
References
[1] Bonica JJ: The Management of Pain. 4Th ed. Philadelphia, Lea & Febiger; 2009: 972-999.
[2] Headache Classification Subcommittee of the International Headache Society. The international Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24:9-160.
[3] Pope JE, Narouze S: Orofacial Pain. In: Benzon HT, ed. Essentials of Pain Medicine. 3Rd ed. Philadelphia, PA: Saunders; 2011: 289-293.
[4] Mott AE, Grushka M, Sessle BJ. Diagnosis and management of taste disorders and burning mouth syndrome. Dent Clin North Am 1993;37:33-71.
[5] Berman LH. Contemporary conecepts in endodontics: 2003 and beyond. Gen Dent. 2003;51:224-230.
[6] Bayer DB, Stenger TG: Trigeminal neuralgia: an overview. Oral Surg Oral Med Oral Pathol 48 (5): 393–9.
[7] Lee AG, Beaver HA, Brazis PW. Painful ophthalmologic disorders and eye pain for the neurologist. Neurol Clin N Am 2004;22:75-87.
[8] Del Catillo F, Corretger JM, Medina J, et al. Acute otitis media in childhood: a study of 20,532 cases. Infection 1995;23(suppl 2):70-73.
[9] Scarbrough TJ, Day TA, Williams TE, et al. Referred otalgia in head and neck cancer: a unifying schema. Am J Clin Oncology 2003;26:157-162
- Hydrodissection – Science or Science Fiction - March 23, 2021
- Facebook Live 2 – Full Video - April 2, 2020
- (Full Presentation) Top 5 Things Pain Patients Need To Know During The Coronavirus Pandemic - March 30, 2020
