Facial Pain

Facial pain is significant to the patient, not only in terms of the pain itself, but due to the varying aetiologies. These can range from benign to potentially lethal. Some have a relatively unimportant cause, others have no obvious organic cause, while others threaten important faculties or can threaten life.

Diagnosis

Obtaining a thorough pain history is crucial to obtaining the correct diagnosis:

SITE- Is the pain localised (tooth-related, trigeminal neuralgia) or diffuse (atypical facial pain)? Is it restricted to one side of the face or does it cross the midline?

ONSET- When did the pain first occur? Was the onset gradual or sudden?

CHARACTER- What kind of pain is it? Is it sharp or dull? Aching or shooting?

RADIATION- Does the pain spread to any other site?

ASSOCIATED FACTORS- Are there any other symptoms that appear with the pain?

TIME/DURATION- How long does each episode of pain last? Transient (dentine-related), Lasting a few seconds (trigeminal neuralgia), lasting 30-45 minutes (migrainous neuralgia) or persistent (atypical facial pain)? Does the pain follow a specific pattern? A ‘pain diary’ can be of some use.

EXACERBATING/RELIEVING FACTORS- Does anything cause the pain to come on, to worsen or to be relieved? Heat may worsen dental pain, touching a trigger zone may worsen trigeminal neuralgia and alcohol can cause an episode of migrainous neuralgia.

SEVERITY- On a scale of 1 to 10, where does this pain lie? Disturbance of sleep will indicate a quite severe pain.

Investigation and Management

INVESTIGATION

The pain history and clinical examination often forms a large part of the diagnosis of facial pain. It is important to identify whether there is an organic cause for the pain; in some cases, a diagnosis may only be reached when organic disease has been excluded. A number of diagnostic tools are available, including blood tests, imaging techniques and pathological investigation. Referral for specialist investigation and managment is often indicated and a multi-disciplinary approach should be employed.

Blood Tests

FBC; may show a raised white cell count in infection or malignancy.

ESR; raised in infection and temporal arteritis.

Imaging Techniques

RADIOGRAPHY; with or without contrast media. A simple and widely available tool. Using contrast media can outline duct systems or salivary glands (sialography) as well as hollow lesions such as cysts or blood vessels (angiography).

COMPUTERISED TOMOGRAPHY (CT); with or without contrast media. Useful where complex anatomy hinders the interpretation of plain radiographs. they deliver a higher x-ray dose but are useful in the identification of tumours.

MAGNETIC RESONANCE IMAGING (MRI); Useful in the identification of soft tissue lesions, space occupying lesions and demyelinating disease.

Pathology

FINE NEEDLE ASIPIRATION BIOPSY; Useful as a rapid diagnostic aid in lymph node or parotid gland swellings. they are able to distinguish between malignant and benign neoplasms whilst avoiding the potential spread of tumour cells.

INCISIONAL BIOPSY; particularly in giant cell arteritis diagnosis.

 

MANAGEMENT

The managment strategies available for the relief of chronic facial pain rely on an accurate diagnosis and are usually undertaken in a hospital setting.

Outline for the management of facial pain;

ELIMINATION OF SYSTEMIC DISEASE AND LOCAL CAUSES or the management of these diseases if diagnosed.

COGNITIVE BEHAVIOURAL THERAPY OR COUNSELLING; this can help patients develop pain management skills, understand their pain and reduce the impact of chronic pain on their quality of life.

PHARMACOLOGICAL MANAGEMENT; Antidepressant therapy, with the effect due to alteration of the sensory discriminative component of pain rather than the antidepressant property, anticonvulsants, opiates or NSAIDs though they usually do not offer much pain relief in chronic facial pain.

Differential Diagnosis of Facial Pain

Structures causing Facial Pain

Neurological Disorders:

Referred Facial Pain