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Facial Pain

Facial pain presents a unique challenge for physicians and healthcare providers, due to its wide ranges of etiologies, which can be neurological or non-neurological in nature. Therefore, patients who suffer from face pain understandably remain confused as to what type of medical specialist they should consult when they develop pain in face, especially when it becomes chronic. Patients often see many types of doctors, including dentists, ear, nose and throat (ENT) specialists, pain specialists, neurosurgeons and neurologists. This can be confusing and time-consuming for patients. Of course, it is very important that patients with facial pain consult with correct provider in order to get the correct diagnosis and proper treatment.  Without a correct diagnosis, patients can end up having incorrect treatment which sometime can even harm the patients or even intensify the pain and discomfort. 

Facial pain can be debilitating to one’s livelihood and wellbeing. 

It is important that physicians take every patient’s complaint of facial pain seriously. This includes gathering a thorough history plus exam of head, teeth, eyes, noses, throat, and even neck, since any of these structures can contribute to facial pain. In addition, if a neurological condition is suspected as the reason for facial pain, a detailed neurological exam, preferably conducted by a neurologist is required. 

At UC San Diego Health, we offer a multidisciplinary approach to facial pain with our team of world-renowned specialists who have expertise in facial pain management.To determine the right treatment, we use a systematic approach to find the source of the pain, beginning with a detailed history and targeted physical examination, which may lead to specialized testing.

Diagnosis

What is needed to make a proper diagnosis?

History is the mainstay for diagnosis. History should include key components in order to extrapolate a specific differential diagnosis:
  • First, the timing of the pain needs to be determined, including when the pain started, how long the pain lasts, and how often the patient experiences the pain. 
  • The location and radiation can be strong determinants of the source of pain.
  • The clinician should then assess the quality and severity of the pain. 
  • Quality is usually documented with modifiers such as throbbing, stabbing, jabbing, and electric-shock like, pressure, burning, dullness, or sharpness.
  • Severity can be assessed using pain scales, such as the visual analogue scale (VAS). The VAS ranges from 1 to 10, with 1 being minimal pain and 10 being the worst pain imaginable. 
  • Then, the physician should evaluate the relieving and aggravating factors of the pain.
  • Next, the impact of the pain should be assessed and how the patient’s quality of life is when dealing with this pain. 
  • The physician should ask if the patient can sleep with the pain, if the patient can concentrate and still perform at an adequate level at his or her job with the pain, and if the patient feels fatigued by the pain. 
  • Finally, the physician should document a detailed medical, family, and social history while ruling out any history of dental disease, orofacial disease, or surgery prior to the initial onset of symptoms.
Prior to their consultation visit, patients who come to our clinic are asked to fill out our detailed questionnaire. This questionnaire addresses all of the areas of concern and details mentioned above.

Anatomy of Trigeminal nerve 

There are 12 cranial nerves in human. The “trigeminal nerve”, which is cranial nerve number 5, is the main sensory nerve of the head innervating the skin of the face, mucosa of the mouth, nasal cavity and sinuses . This nerve originates inside the brain from an area called the brainstem, and then comes to face and becomes three distinct branches as shown in the picture:
Branch 1 (V1): Ophthalmic Nerve 
Branch 2 (V2): Maxillary Nerve 
Brach 3(V3): Mandibular Nerve 
Each nerve, branched to smaller nerve and supply different part of face, gum and teeth as shown in picture.



Causes

Common causes of Facial Pain 

Any injury to this nerve, either inside or outside the brain, can cause facial pain. 

1. Primary( Classical ) Trigeminal Neuralgia 
  • Trigeminal neuralgia is a rare condition with an annual incidence of 4 to 13 cases per 100,000 people. These incidences increase with age, and most cases begin after age 50. Often with the first attack occurring the late 50s or 60s and it is rare before the age of 40.
  • Trigeminal neuralgia is more common in women, which is likely due to women’s increased longevity when compared with men.
  • Classical trigeminal neuralgia which used to known as tic douloureux, often produces recurrent and abrupt “electric shock-like” pain. 
  • Pain usually trigger by touching the face , Chewing , Brushing teeth  , cold win like car AC or even talking , laughing or kissing.
  • Classic trigeminal neuralgia affects one or more branches of the trigeminal nerve, most commonly in the second or third division (V2 andV3) . 
  • Most of the time, it is caused by compression of a blood vessel at the root (entry zone ) of the trigeminal nerve in the brainstem area.
  • In practice, a majority of patients who have facial pain are diagnosed as having Trigeminal Neuralgia, when in fact most do not have this condition. 
2. Secondary Trigeminal Neuralgia 
  • While classic trigeminal neuralgia can occur in patients under age 50, it is very important to consider other diagnoses in those younger than 50, particularly in patients below age 40 or in those who have sensory symptoms, such as “tingling” or “numbness”. Patients with face pain who also experience numbness or tingling in the area of pain are usually classified as trigeminal Neuropathy (see below). 
  • The most common etiologies for secondary trigeminal neuralgia are multiple sclerosis, tumor, or vascular malformation. 
  • With obtaining proper imaging (MRI, CT, MRA, CTA), which we select based on clinical suspicions, all of these etiologies can be diagnosed. 
3. Trigeminal Neuropathy 
  • Injury or dysfunction of the trigeminal nerve, which usually presents with numbness, tingling, pain or a burning sensation, is known as trigeminal neuropathy. Since pain is usually the most bothersome component, we sometimes use the term Trigeminal Neuropathic pain in these patients. 
  • Injury to the nerve can be anywhere from the brainstem (root), where the pain originates, to the very peripheral branches of this nerve, where it supplies the gum and teeth. Therefore, trigeminal neuropathy can have a wide range of differential diagnoses. Therefore, it is critical to differentiate trigeminal Neuropathy from trigeminal neuralgia, since treatments may differ. Not only is the most effective treatment for trigeminal neuralgia (MVD, see treatment section) not an option for trigeminal neuropathy, but it also might worsen the condition.  With a detailed history and exam, it is not difficult to differentiate between trigeminal neuralgia and trigeminal neuropathy or trigeminal neuropathic pain. 
4. Migraine 
  • One the most common reasons for facial pain, which can be mistaken as trigeminal neuropathic pain or trigeminal neuralgia, is migraine. 
  • While migraine is mostly known as headache, it can be present with face pain on one or both sides, considering the major role of trigeminal pathway in migraine. 
  • Since this is a very common misdiagnosis of facial pain, the International Classification of Orofacial Pain (ICOP) published a classification in 2020, which utilizes the term “Orofacial Migraine” for patients who have migraine without headache and solely have face pain. This classification is available for all healthcare providers around the world to review and use in clinical practice with the hope that patients with migraine are not diagnosed as having trigeminal neuralgia. 
5. Trigeminal Autonomic Cephalalgia (TAC)
  • TAC is another class of headache disorder, which can be commonly mistaken as Trigeminal Neuralgia. This is due in particular to the fact that aside from some neurologists, most the other specialists are unfamiliar with this class of headache disorder. Therefore, it can easily be missed. 
  • This class of headache disorders present with pain on one side of the face, which is unusually around the eye and upper cheek, and sometimes with radiation to the top and back parts of head. 
  • Based on the duration of pain (seconds, minutes, hours, or constant), TAC is classified into four subgroups. Cluster Headache is the most common  subgroup of TAC . 
6. Dental etiology 
  • Tooth problem is a very common reason for facial pain. This could be due to a simple cracked tooth (calls as pulpal pain) or more severe periodontal disease or inflammation of gum (gingivitis) . 
  • Since pain in a tooth (pulpal pain) can refer (radiate) to same side of face, it easily can be present with face pain and mistaken as trigeminal neuralgia, although dental pain is usually constant while trigeminal neuralgia is not . 
  • In practice, a large percentage of patients with facial pain referred to neurology or neurosurgery clinics, had multiple procedures on teeth and the oral cavity. Therefore, most of these patients suffer from “facial pain attributed to trauma to dental structure or injury to the branches of trigeminal nerve”. 
  • Subsequent to trigeminal nerve injury, the patient will experience reduced quality of life, psychological discomfort, social disabilities, and handicap. Patients often find it hard to cope with such negative outcomes of dental surgery since the procedure is often elective and the patient expects significant functional or aesthetic improvements. 
  • Altered sensation and pain in the orofacial region may interfere with speaking, eating, kissing, and shaving, applying make-up, tooth brushing and drinking; in fact this condition affects just about every social interaction. 
7. Temporomandibular Joint (TMJ) disorder 
  • This is another etiology for face pain that is sometimes mistaken with trigeminal neuralgia. 
  • TMJ pain could be primary, which means it has no known causative disorder, or could be secondary, which means another causes it identified disorder. Its causes could be trauma, infection, crystal deposition, autoimmune disorder, disc displacement, or osteoarthritis. 
8. Trauma 
  • Facial trauma, mostly due to sport injuries or motor vehicle accidents can cause facial pain either due to damage to structure of the face (nociceptive pain) or injury to trigeminal nerve (neuropathic pain). 
  • It is important to recognize this etiology, since often in practice we see most of these patients as being labeled having “trigeminal neuralgia”. 
9. Post-Herpetic Neuralgia 
  • Trigeminal neuropathic pain after shingles, with also known as “post-herpetic neuralgia” is another well-known reason for facial pain, and can be extremely painful. 
  • Besides medication management, we offer intervention, including nerve stimulator for these patients. 
10. Tumors
  • Cysts, benign tumors and malignancies, either primary or metastatic, can occur in any structure of face, including oral mucosa, nose, and paranasal sinuses and any of these can present with face pain. Sometime it is critical that this type of patients diagnose quickly since treatment might be time sensitive.  
11. Systemic autoimmune disorders
  • The most challenging class of trigeminal neuropathy involves patients who do not belong to any of groups /etiologies which discussed above. 
  • Both the International Classification of Headache Disorder (ICHD) and international Classification of Orofacial Pain (ICOP) has a section in their classification, which is “Trigeminal neuropathic pain attributed to other disorder”.
  • These are the patients requiring need further investigation to identify the reason for the trigeminal pain. Within the last few years, we diagnosed a large percentage of these undiagnosed patients with autoimmune disorders. Some autoimmune disorders such as Sjögren syndrome, Scleroderma, Lupus, and Undifferentiated Connective Tissue Disorder can attack the trigeminal nerve and cause pain. 
  • This class of patients are very likely to be labeled as having “trigeminal neuralgia”, even though most of them experience sensory symptoms (tingling and numbness), which we should not  see in classical trigeminal neuralgia . 
  • We refer to this group of patients as having “Autoimmune Trigeminal Neuropathy”. Since this is a new category of facial pain, treatment options are not well studied. Patients who suffer from face pain, particularly if it began before age 40 and is associated with tingling or numbness, should be considered for this diagnosis as a possibility. 
  • We discuss and outline the treatment options after we diagnose the type of autoimmune disorder with patients. Most of the time treatment is medical. Surgical treatment, particularly MVD, usually has a very poor outcome in this class of patients since manipulating a nerve that already been injured due to an autoimmune disorder can often worsen the pain.  
12. Other causes of Facial Pain 
  • Disorders of any structures that have nerve supply with the trigeminal nerve, can also cause face pain. Examples include eye disease (e.g. uveitis), paranasal sinus disease such as infection (particularly fungal) , nose abnormality (contact point , concha bullosa) which also rare causes of face pain but needs to be in consideration . 

Treatments

Pharmacological Treatment


The type of medications we prescribe depends on the cause of face pain, as different medical treatment options can be effective. Since some of these medications may have side effects during the course of treatment, regular follow-up and blood work may be necessary.

For classic trigeminal neuralgia, Carbamazepine and its family of drugs (e.g. Oxcarbazepine) is the gold standard treatment. Besides possible side effects, Carbamazepine is associated with dose-limiting side effects, particularly with prolonged usage. This is a major problem in the long-term treatment of classical trigeminal neuralgia. Therefore, we recommend “surgical consultation” and treatment (see below) sooner rather than later in this class of patients.  Additionally, this class of medication can have drug interactions with some medications, which the patient might be taking and therefore physicians who prescribing these medication needs to be aware of drug-drug interaction. 

When we start the patient on carbamazepine (Tegretol) or oxcarbazepine (Trileptal), we do regular blood work, since these medications can cause abnormalities in serum sodium levels, liver enzymes, and white blood cells, which could cause serious complications if not screen and diagnosed early.

Other medications, including Gabapentin (Neurontin) and Pregabalin (Lyrica) can be used as second line and can be partially effective. It is important to note that the dosage needed to control trigeminal pain is relatively high, which might cause adverse events, making these treatment options intolerable for the patient. 

There are several other medications which have been tried and used in trigeminal neuralgia, however, none are backed by strong evidence and are unlikely to be effective. 

Holistic Treatment 


Some patients with facial pain benefit from holistic therapeutic options, such as massage or acupuncture.  
We strive to balance our treatments so that patients have access to different facets of medical care, including holistic treatment. We offer acupuncture services in our clinic for patients with facial pain.

Procedural Treatment


Procedural treatments for face pain range from injections, such as peripheral nerve blocks (particularly inferior alveolar nerve), occipital nerve blocks, and sphenopalatine ganglion blocks, to Botox therapy. 

These procedures can both be used as treatment options, and occasionally as diagnostic tools to help understand the precise origin of pain. 

None of these treatment has been approved for classical trigeminal neuralgia. Therefore, insurance companies often do not approve these injection treatment. Since some of these procedure, particularly Botox are relatively expensive, these option have limited use in practice.