Craniofacial pain syndromes
Possible pathways for facial pain include: trigeminal nerve (portio major as well as portio minor (motor root), facial nerve (usually deep facial pain), and eighth cranial nerve.
Etiologies
1. cephalic neuralgias
a) trigeminal neuralgia
● vascular compression of Cr. N. Vat root entry zone: the most common cause
● MS:plaque within Cr.N.V nucleus.
b) glossopharyngeal neuralgia: pain usually in base of tongue and adjacent pharynx.
c) geniculate neuralgia: otalgia and deep prosopalgia
d) tic convulsif: geniculate neuralgia with hemifacial spasm.
f) superior laryngeal neuralgia: a branch of the vagus, results primarily in laryngeal pain and occasionally pain on the auricle
h) herpes zoster:pain is continuous(not paroxysmal).Characteristic vesicles and crusting usually follow pain, most often in distribution of V1 (isolated V1 TGN is rare). In rare cases without vesicles, diagnosis may be difficult
i) postherpetic neuralgia (Ramsay-Hunt syndrome)
k) trigeminal neuropathic pain (AKA trigeminal deaffeerentation pain): may follow injuries from sinus or dental surgery, head trauma
l) trigeminal deaffeerentation pain: follows trigeminal denervation including therapeutic measures to treat trigeminal neuralgia.
m) short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT): rare. Usually affects males 23–77 years old. Brief (<2 minutes) pain (burning, stabbing or shock-like) usually near the eye, occurring multiple times per day. Associated autonomic findings (the “hallmark of SUNCT”): ptosis, conjunctival injection, lacrimation, rhinorrhea, hyperemia. May be due to CPA AVM. Microvascular decompression or trigeminal rhizotomy may be effeective in some cases refractory to medical treatment with AEDs or corticosteroids. Note: lacrimation (the most common) or other autonomic signs may occur in V1 trigeminal neuralgia but are usually mild, and appear only in the later stages of the condition and with long lasting attacks.
Dramatic lacrimation and conjunctival injection from the onset of symptoms with SUNCT are the best characteristics to distinguish this from trigeminal neuralgia. May also occur in cluster headache (p.175).
2. ophthalmic pain
a) Tolosa-Hunt syndrome: painful ophthalmoplegia.
b) (Raeder’s) paratrigeminal neuralgia: unilateral Horner’s syndrome + trigeminal neuralgia
c) orbital pseudotumor: proptosis, pain, and EOM dysfunction
d) diabetic (oculomotor) neuritis
e) optic neuritis
f) iritis
g) glaucoma
h) anterior uveitis
3. otalgia
4. masticatory disorders
a) dental or periodontal disease
b) nerve injury (inferior and/or superior alveolar nerves)
c) temporo-mandibular joint (TMJ) dysfunction
d) elongated styloid process
e) temporal & masseter myositis
5. vascular pain syndromes
a) migraine headaches: see Migraine.
● simple migraine: includes classic migraine, common migraine
● complicated migraine: includes hemiplegic migraine, ophthalmoplegic migraine
b) cluster headache; subtypes: episodic, chronic, chronic paroxysmal hemicrania
c) giant cell arteritis (temporal arteritis). Tenderness over STA
d) toxic or metabolic vascular H/A (fever,hypercapnia,EtOH,nitrites,hypoxia,hypoglycemia, caffeeine withdrawal)
e) hypertensive H/A
f) aneurysm or AVM (due either to mass effect or hemorrhage)
g) carotidynia: e.g. with carotid dissection
h) basilar dolichoectasia with fifth n. compression or indentation of the pons
6. sinusitis (maximally, frontal, ethmoidal, sphenoidal)
7. dental disease
8. neoplasm: may cause referred pain or fifth nerve compression
a) extracranial
b) intracranial tumor: primarily posterior fossa lesions, neoplastic compression of trigeminal nerve usually causes sensory deficit
9. atypical facial pain (AFP) (prosopalgia): traditionally a “wastebasket” category used for many things. It has been proposed to reserve this term for a psychogenic disorder. May be suspected by
10. primary (nonvascular) H/A: including
a) tension (muscle contraction) H/A
b) post-traumatic H/A