Diagnosing and treating facial pain

Authors reviewing the evaluation and treatment of facial pain say it's unfortunate that atypical facial pain has "taken on a pejorative connotation and become a diagnosis unto itself instead of one of exclusion".Dr Hentschel and colleagues from the Mayo Clinic discuss the approach to patients with cranial neuralgias, postherpectic neuralgia, dental root pain, temporomandibular dysfunction, and atypical facial pain. They say that a thorough clinical evaluation is mandatory in all patients, including those where the pain can be nondescript, chronic and without any identifiable source.Atypical facial pain "has become an umbrella term applied to facial pain of indeterminate origin," and is often attributed to underlying psychologic stress, the authors say. However, the cause is most often organic, even if not clearly identified, and requires exhaustive diagnostic evaluation to rule out "potentially sinister as well as treatable underlying causes". A diagnosis of atypical facial pain can only be made after causes such as nasopharyngeal carcinoma, pulmonary carcinoma, abscesses, cracked tooth syndrome and sinusitis are ruled out. Treatment in true cases of atypical facial pain involves biofeedback, relaxation therapy and biobehavioural techniques. Tricyclic antidepressants are also useful, as much for their pain relieving action as for their antidepressant effects.The clinical features and secondary causes of trigeminal neuralgia are described in the review. Although most cases are idiopathic, pain spreading to involve the ear, occiput, neck or chest or cases in patients younger than 40 may indicate a secondary cause. Postherpetic neuralgia is differentiated from trigeminal neuralgia by involvement of the first division of the trigeminal nerve and paroxysmal lancinating pain superimposed on a continuous gnawing pain. A recent evidence-based practice parameter by the American Academy of Neurology suggests tricyclic antidepressants and a number of other agents for pain relief....