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One of the most common reasons that patients see me in clinic is for facial pain. Some of these patients have sinusitis, but the vast majority of some other facial pain syndrome. Of these “non sinusitis patients” with facial pain, migraines are the most common.
However, we do occassionally see patients that have neuralgia pains, and its important to identify these patients, because the treatments are different than for other headaches. And the pain is often severe. So making the correct diagnosis is important to treating the patient.
Neuralgia-related pains that mimic sinusitis
There are several neuralgia types of pain that occur in the head and face that mimic sinusitis and for that matter may mimic migraines or other severe headaches. It is important to identify these because the workup and treatment of these disorders is substantially different and because these headaches are typically quite severe and incapacitating. The two most common types of neuralgia, or nerve related pains, are trigeminal neuralgia and atypical facial pain. Although they share many similar characteristics, each of them have particular features that usually make it possible to discriminate between them.
The pain of trigeminal neuralgia is a severe sharp, shooting, or electrical shock type a sensation that lasts seconds to a couple of minutes and is almost always unilateral. The pain arises over the trigeminal nerve, which has three branches. The trigeminal nerve has a branch over the eye (frontal division), a branch between the eye in the upper lip (maxillary division), and a branch near the chin (mandibular division). The maxillary or mandibular nerves are more frequently involved than the frontal division. Of course pain in the lower jaw does not typically make one suspicious of the sinus infection. However pain over the cheek and brow is frequently confused for sinus-related disease as well as dental-related disorders. In about 90% of patients with trigeminal neuralgia, there is a trigger zone in the face were a light touch type of stimulation will trigger the severe, lancinating in any pain. The light touch stimulus could include chewing, talking, washing one’s face, brushing teeth, facial movement, cold air or when. After the sharp, Lance many pain, there may be a dull ache for a few minutes.
A physician’s workup for trigeminal neuralgia will entail a search for any disease along the course of the trigeminal nerve or the division of the trigeminal nerve that is involved. This will often entail an evaluation of the skin, cheek, nose, cranial nerves, head, and neck as well as focused general and neurologic examination. Usually a CT scan or MRI is also helpful to rule out a lesion along the nerve that cannot be assessed by direct physical examination, for instance a tumor at the base of skull or deep within the maxillary sinus. MRI scans have the advantage of assessing being able to identify very fine, discrete lesions near the nerve as well as assessing for abnormalities of the soft tissues of the face and skull. A substantial number of patients with classic findings of trigeminal neuralgia are found to have a small vascular loop, that is a small blood vessel, that compresses or pulsates against the trigeminal nerve in the region of the brain which is just prior to its exit from the skull. In less than 5% a cases, a tumor on or near the trigeminal nerve is identified. An MRI scan also will identify an occasional patient with multiple sclerosis.
Treatment of Trigeminal neuralgia
Treatment of trigeminal neuralgia is is often successful once the correct diagnosis is made. Patients with vascular loops causing compression of the nerve are candidates for nerves surgical evaluation and possible decompression of the nerve. Otherwise medications are often effective for management of the pain. Similar to treatment of migraines, this prophylactic medication is usually initially taken at low doses, with gradual increasing doses, week by week, until pain relief is accomplished or side effects occur. Intolerable side effects may necessitate trial of an alternative drug. For patients who cannot get relief from many medical therapy, surgical approaches to the nerve are possible but each of the surgical approaches are invasive and are associated risks of side effects or failure that require thoughtful consideration on the part of the patient and surgeon alike. Some of the more commonly used medications to control our trigeminal neuralgia include tricyclic antidepressants, carbamazepine, oxcarbamazaepine, gabapentin, phenytoin, baclofen, clonazepam, valproate, and pimozide. While some of the medications require little or no monitoring long-term, others require monitoring for blood or liver side effects, which the patient should discuss with his or her physician. Once properly identified, these conditions are frequently treated by our neurologists or by one primary care physician.
Atypical facial pain
Patients and their fourth or fifth decades of life in a described as a steady deep ache, boring, pain that can last hours or days at a time or longer. The most common location is over the second branch of the trigeminal nerve, below the eye or along the side of the nose or the nasal labial region (the cheek fold). Atypical facial pain often begins after a dental procedure or after significant facial trauma. When specifically questioned, patients will admit to numbness over the cheek after a procedure or injury that precedes the onset of the pain. The painful region will often be sensitive to light touch, which is quite characteristic of neuralgia pains or nerve-type of pains. Gently brushing the area with a finger or even a cotton ball will cause discomfort far out of proportion to the stimulus. Gently touching the area will sometimes be associated with a tingling or “ants crawling on my skin” feeling. In fact, after the initial injury that causes a numbness, patients will sometimes recall a period of tingling sensations which subsequently may be replaced by the facial pain or occur intermittently with the facial pain.
Patients with atypical facial pain will usually seek care from primary physicians, dentists, neurologists, or otolaryngologists. It is not unusual for patients to undergo multiple dental extractions searching for a tooth root that may be infected in causing the pain, but usually to no avail.
Treatment of atypical facial pain is similar to that of trigeminal neuralgia. Low doses of tricyclic antidepressants, increasing in dosage slowly on a weekly basis until pain is controlled or side effects become intolerable, are often effective.
When I diagnose patients with trigeminal neuralgia or atypical facial pain, I usually refer them back to a local neurologist for long term management and potentially further workup for a “cause”.
Jeffrey E. Terrell, MD