FACIAL PAIN: UNDERSTANDING THE CAUSES AND TREATMENT OPTIONS

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Facial pain may stem from several causes. The first step in effectively treating facial pain is diagnosing the origin of the pain. Causes of facial pain include:​​​​​ 

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• Nerve Pain and Neurological Causes

  • Trigeminal Neuralgia: A sharp, electric shock-like pain caused by irritation of the trigeminal nerve.

  • Multiple Sclerosis: A neurological condition that may cause facial pain due to nerve damage, though it's typically distinct from AFP.

  • Nerve Compression Syndromes: Pressure on facial nerves can lead to pain.

  • Cranial Nerve Compression: Compression of other cranial nerves can cause facial pain.

  • Nerve Entrapment Syndromes: Trapped or compressed nerves can cause pain in the face.

• Headache Disorders

  • Primary headcahe disorders including migraine, tension-type headache and cluster headache can sometimes cause facial pain due to referred pain or overlapping symptoms.

• Structural and Physical Causes Associated with Facial Pain

  • Temporomandibular Joint (TMJ) Disorders: Dysfunction in the jaw joint may cause localized facial pain.

  • Muscle, Tendon, and/or Joint Pain: Muscle tension in the face or jaw can lead to persistent pain.

  • Previous Facial Trauma: Injuries to the face can sometimes lead to ongoing pain in the affected area.

• Systemic and Inflammatory Conditions

  • Autoimmune Disorders: Conditions such as rheumatoid arthritis and lupus can cause systemic inflammation that affects nerves, leading to facial pain.

  • Chronic Inflammatory Processes: Conditions like fibromyalgia can heighten pain sensitivity in the face.

  • Immune System Dysregulation: Autoimmune or immune-related conditions may contribute to chronic pain syndromes, including facial pain.

• Dental Pain

  • Tooth infections or issues can sometimes cause facial pain, especially if they affect nerves in the jaw or teeth.

• Pain Due to Underlying Medical Conditions

  • Other systemic or chronic conditions, such as vascular issues, can occasionally cause facial pain as part of broader health conditions.

• Atypical Facial Pain

  • Atypical Facial Pain (also known as persistent idiopathic facial pain) is a type of facial pain where we don't know the exact cause. It is not fully understood but believed to be neuropathic in origin. Atypical facial pain is diagnosed after ruling out other potential causes of facial pain including TMJ disorders and headache disorders.

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REFERRED PAIN

Facial pain often, but does not always, involve referred pain, meaning the source of the pain might not be where you feel it. In other words, pain in the face can originate from other areas of your body, such as the neck or jaw, making diagnosis more complex. 

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NERVE PAIN

Sometimes, facial pain may present as neurogenic or neuropathic in nature, where the nerves in the face fire abnormally, sending pain signals even when there is no injury. When nerves fire for a prolonged period of time, such as in a chronic pain condition, the surrounding nerves become sensitized. Nerve-related pain is often described as lancinating (sharp, shooting), burning, and electric. Nerve pain may be paroxysmal in nature or constant with varying degrees of intensity. Cranial neuralgias often present as paroxysmal. Neuropathic or nerve-related pain is not completely understood and is believed to have several causes some of which are unknown (such as cranial neuralgias including trigeminal neuralgia and glossopharyngeal neuralgia) and others related to an underlying medical condition (such as viruses) or trauma. Chemotherapy may also induce neuropathic pain. 

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HOW DO I DIAGNOSE FACIAL AND NERVE PAIN?

Your visit will start with a detailed history taking during which we will take a deep dive into understanding your pain story. We will also discuss your medical history and sleep hygiene. A detailed history taking is crucial for diagnosis, and thus I devote extensive time to this part of the exam. Then, I will perform a thorough evaluation that includes evaluating your neck, cranial nerves, jaw joints, facial and neck muscles and oral cavity. During this evaluation, I am assessing not just the painful regions but also the origins of the pain as facial pain often involves referred pain.

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The diagnostic process includes:

• Comprehensive physical examination of the head, face, neck, jaw and oral cavity

• Cranial nerve and cervical evaluation

• Imaging (if necessary) to confirm the diagnosis

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TRIGEMINAL NEURALGIA

Trigeminal neuralgia (TN), also called tic douloureux, is a nerve-related facial pain condition that affects the fifth cranial nerve. The trigeminal nerve provides the majority of sensory innervation to the face, jaw, and teeth. It is comprised of three divisions: ophthalmic, maxillary, and mandibular. Often, the mandibular and maxillary divisions are commonly affected in this neural condition. Trigeminal neuralgia is often categorized into two types:

• Classic TN: Characterized by brief, shock-like, electric pain, often triggered by light touch, eating, or speaking.

• TN with continuous pain: Involves ongoing moderate pain with bursts of more intense pain.

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What are the symptoms of trigeminal neuralgia?

Trigeminal neuralgia is typically classified as classic trigeminal neuralgia, formerly referred to as type 1, or trigeminal neuralgia with concomitant continuous pain, previously referred to as type 2. Classic trigeminal neuralgia presents as paroxysmal in nature and is often described as lancinating and producing an electric-like sensation. Often, daily activities, such as eating or speaking, and normal stimulation, such as a gust of wind brushing against one's face may trigger an episode. The pain is brief, shock-like and may be provoked by a light touch. By contrast, trigeminal neuralgia with concomitant continuous pain presents as continuous neural pain that is moderate intensity but is accompanied by brief bursts of a burning, aching sensations. Trigeminal neuralgia may develop in areas devoid of infection or dental conditions. Thus, individuals suffering from TN may complain of pain and point to a tooth that is intact without any evidence of infection, cavity or fracture.

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How do we diagnose trigeminal neuralgia?

The first step in diagnosing trigeminal neuralgia is a thorough evaluation and review of your history. Dr. Levi will review what triggers your symptoms. She will perform a comprehensive examination of your head, face, and neck, and she may order imaging to confirm a diagnosis.

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How is trigeminal neuralgia treated?

Conservative therapies such as medications are usually the first line of treatment. Additionally, Botox injections and nerve blocks are sometimes indicated and may be effective. 

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Besides trigeminal neuralgia what are some other neuralgias that Dr. Levi treats?

In addition to trigeminal neuralgia, Dr. Levi also treats other forms of neuralgia, such as:

• Post-herpetic neuralgia (pain after herpes infection such as shingles)

• Occipital neuralgia (pain at the base of the skull)

• Glossopharyngeal neuralgia (pain in the throat or ear area)

• Nervus intermedius neuralgia

• Superior laryngeal neuralgia (pain in the throat)

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CHEMOTHERAPY-INDUCED NEUROPATHIC PAIN

Orofacial neuropathic pain is extremely common in cancer patients and may be related to head and neck radiation therapy, head and/or neck surgery, chemotherapy, a stem cell transplant, or the underlying cancer. Certain chemotherapies are associated with neuropathic pain.

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What does neuropathic pain associated with chemotherapy feel like?

Similar to other neuropathic pain, chemotherapy-induced neuropathic pain may present as a toothache or throbbing jaw despite any obvious signs of a dental infection or dental disease. Often, chemotherapy-induced neuropathic pain subsides after treatment.

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How is chemotherapy-related neuropathic pain treated if it does not subside after treatment?

Sometimes, though not common, chemotherapy-related neuropathy may linger and is treated similar to other neuropathic pain conditions. In other words, conservative therapies including medications or injections may be prescribed. 

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ATYPICAL FACIAL PAIN

Atypical facial pain (AFP), also known as persistent idiopathic facial pain, is a chronic condition characterized by persistent, poorly localized facial pain that does not follow typical patterns of nerve or tissue damage. The pain is often described as aching, burning, or stabbing, and may vary in intensity. It is not associated with any clear, identifiable cause, such as nerve compression, dental issues, or temporomandibular joint (TMJ) dysfunction. AFP is considered a complex and challenging condition to manage.​

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Comprehensive Causes of Atypical Facial Pain

Understanding AFP requires a look at multiple potential contributing factors, including neurological mechanisms, psychological components, and other underlying conditions.

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Neurological Mechanisms

• Trigeminal Nerve Dysfunction: Abnormal signaling in the fifth cranial nerve can lead to facial pain.

• Central Sensitization: This occurs when the central nervous system amplifies pain signals, making normal sensations feel like pain.

• Neuroplastic Changes: Over time, the brain and nervous system may adapt to pain, leading to changes in how pain is processed and perceived.

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Key Characteristics

Patients with atypical facial pain typically experience:

• Persistent, unexplained facial pain that may occur continuously or intermittently

• Pain that does not follow typical nerve pathways and can be felt in various locations on the face

• Varying intensity of pain, which can be sharp, throbbing, or burning

• Symptoms that last for months or years

 

Diagnostic Approach

Identifying atypical facial pain requires a comprehensive evaluation to rule out other potential causes and pinpoint the underlying mechanisms of pain. The diagnostic process involves several key steps:

1. Detailed Medical History
   A thorough discussion about the onset, duration, and nature of the pain is essential. Dr. Levi will inquire about the pain’s characteristics, such as whether it is constant or intermittent, its intensity, and its location. The medical history will also cover previous conditions, medications, injuries, and treatments that could provide insight into potential causes of pain.

2. Examination
   A careful examination is performed to assess the facial muscles, jaw movement, and sensitivity. We will look for signs of nerve involvement, muscle dysfunction, or other structural issues contributing to the pain. Cranial nerve evaluations will help identify nerve pathologies.

3. Advanced Imaging Studies
   Imaging techniques, such as MRI or CT scans, can help visualize the structure of the facial bones, joints, and nerves. These scans can identify issues like cranial nerve compression, tumors, or structural problems such as disc displacement in the TMJ. Advanced imaging also helps evaluate neurological conditions like multiple sclerosis, which may contribute to facial pain.

4. Multidisciplinary Approach
   Dr. Levi works with a multidisciplinary team to treatm atypical facial pain and provide a multifaceted treatment plan that is tailored to each patient.

5. Ruling Out Other Potential Pain Sources
   Part of the evaluation and diagnosis includes differentiating atypical facial pain from other common conditions that mimic similar symptoms. Ruling out these other causes ensures that atypical facial pain is accurately diagnosed and managed appropriately.

6. Comprehensive Evaluation of Psychological Factors
   Since chronic pain may also be influenced by psychological factors such as stress, anxiety, and depression, mental health screenings may be included as part of the diagnostic process. Addressing the psychological aspects of pain is important because these factors can exacerbate or even contribute to the central sensitization seen in atypical facial pain.

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Treatment Strategies

Managing atypical facial pain often requires a multidisciplinary approach, combining medical treatments with complementary therapies to address the neurological, psychological, and physical aspects of the pain.

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Medical Interventions

• Medications: At times, medications are indicated to treat atypical facial pain and they are often tailored to each patient based on their symptoms. These may also include medications that help regulate nerve activity to prevent the pain signals from becoming amplified.

• Targeted Treatments: For some patients, nerve blocks or other interventional procedures can provide temporary relief.

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Complementary Approaches

• Physical Therapy

• Acupuncture

• Mindfulness and Meditation

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Living with Atypical Facial Pain

Atypical facial pain is a chronic condition, but with the right management plan, individuals can find relief from their pain. It may also be helpful to:

• Maintain open communication with your healthcare providers

• Keep a detailed pain journal to track symptoms and triggers

• Be open to exploring multiple treatment options to find what works best

• Prioritize mental health 

• Maintain a support network of healthcare providers, family, and friends

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Understanding the Complexity

Atypical facial pain is rarely caused by a single factor. Most cases involve intricate interactions between neurological systems, immune responses, psychological states, and even genetic predispositions. This complexity requires a tailored, holistic approach to diagnosis and treatment.

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Knowledge is the first step toward effective management.

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Ready to find relief? Call Dr. Levi today.

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