1. Facial pain

2. Head, neck, and orofacial pain classifications
Introduction
Head, neck, and orofacial pain classifications
Intracranial disorders
1- Neurovascular headache disorders
2- Neuropathic pain disorders
Extracranial pain disorders
1- Intraoral pain disorders
2- Musculoskeletal cervical and temporomandibular disorders
3- Cervical spine disorders
4- Temporomandibular disorders
5- Muscular disorders
Local myalgia
Myofascial pain
Centrally mediated myalgia
Myospasm
Myositis and tendonitis
Muscle contracture
Muscle neoplasia

3. Intracranial and vascular pain disorders
Neurovascular headache disorders:
Primary headache
Secondary headache
Neuropathic pain disorders:
Proxysmal pain disorders
Continuous pain disorders
Headache attributed to associated extracranial pain disorders:
Eye, ear, nose, sinuses, and throat disorders
Extracranial intraoral pain disorders
Teeth and periodontal disorders
Mucogingival, tongue, salivary gland disorders
Musculoskeletal pain disorders
Cervical disorders
Temporomandibular disorders:
Articular disorders
Muscular disorders

4. Investigations
clinical signs and symptoms
clinical examinations
Radiographic exam, CT or/and MRI

5. Trigeminal neuralgia Definition Epidemiology
Disorder of the fifth cranial nerve leading to intense paroxysmal pain within one or more divisions of its sensory supply.
Epidemiology
3-6/ , more common in female. Incidence of severity increase with age. Usual age of onset years

6. Trigeminal neuralgia Cause: Clinical:
compression of trigeminal nerve root by artery in middle cranial fossa
nerve demyelination
Clinical:
Paroxysmal pain within one of the three divisions of trigeminal n, usually maxillary and mandibular divisions.
intense, lancinating, burning pain, ‘’ like an electric shock)
Pain last seconds to minutes only
Frequency varies, may be multiple times/hour
Almost always unilateral
Many patients have a trigger point for their pain, which may be stimulated by everyday tasks, such as eating, talking and washing
Patients have periods of remission and relapse, but symptoms tend to worsen over time.
Neurological examination shows no clinical abnormality

7. Trigeminal neuralgia Investigation Treatment:
Full neurological examination
MRI brain if:
Atypical features
Possible underlying demyelinating disease or intracranial lesion
Microvascular decompression
Treatment:
Medical management (first line)
Anticonvulsant, such as carbamazepine, phenytoin or gabapentin, or a combination.
Carbamazepine started as 100 mg twice daily, up to 1600mg/day
monitor WBC and liver function
require close follow-up and trial reductions of therapy once symptom free

8. Trigeminal neuralgia Surgical Management
Peripheral procedures eg cryotherapy/ chemical destruction with alcohol/ phenol. Radiofrequency ablation to affected branch under LA / GA
central neurosurgical procedures. Artery causing nerve compression is separated from nerve using Teflon sheet
Gamma knife (radiosurgey)
All the above carry risks of permanent paraesthesia, anaesthesia dolorosa (sever continous pain within the distribution of the nerve), and risks associated with the surgical procedure itself. Therefore the surgical approach applied when medical management side effect are intolerable

9. Migraine
Definition primary recurrent headache disorder, more common in females. Termed hemicrania as it effects half of the head.
Cause possibly related to abnormal 5-hydroxytryptamine (5-HT) receptors activity leading initially to vasoconsition of portions of cerebral arteries followed by compensatory vasodilation with cerebral oedema and pain.
Precipitants include:
Hormonal factors
Dietary, e.g chocolate, bananas
stress
sleep deprivation
Bright or flashing lights

10. Migraine Treatment Clinical signs and symptoms
May have preceding aura:
visual hallucination, including flashing coloured lights, loss colour perception or other visual disturbances
motor- temporary muscle palsies
speech disorders including aphasia
Sever unilateral headache :
Initially poorly localised
Becomes localised to temporal, frontal or orbital region.
Photophobia
Nausea
Vomiting
Treatment
Acute attack: analgesics, sumatriptan (5-HT antagonist), ergot derivatives.
Prophylaxis: options include pizotifen (antihistamine), propanolol calcium channel blockers.

11. Cluster Headaches Definition
Recurrent headaches also known as migrainous neuralgia and Horton’s syndrome. Occur in intermittent bouts with interspersed periods of remission. Often positive family history. 80% patients smoke. Presents in third or fourth decade.
Epidemiology
Less common than migraine. male: female = 6:1
Cause
Unknown. Possible allergic basis with mast cell release of histamine and vasodilation, Associated with:
sleep apnoea and decrease oxygen saturations.
Alcohol
Cocaine

12. Cluster Headaches Clinical:
Severe, unilateral episodes of burning or lancinating pain, in and around the orbit, frontal and temporal region.
Abrupt onset, lasts for 15min – 3 hours, often awakens the patient at night.
Begin at same time every day (Alarm clock headache)
May have multiple episodes each day
Occur for 2- 3 months, then have periods of remission that can last for years.
May be associated with autonomic problems:
Conjunctival vessel congestion
Eye watering
Nasal stuffiness
Facial flushing

13. Cluster Headaches Investigation
Diagnosis is clinical. However similar symptoms may be secondary to intracranial pathology, so consider MRI of the brain.
Treatment
Acute attack:
1- Oxygen may abort an attack and its effectiveness is diagnostic
2- Sumitriptan
Prophylaxis:
Nifedipine
Ergotamine

14. Temporal (giant cell) arteritis
Definition Multifocal vasculitis affecting the cranial arteries, of unkown aetiology, with average age of onset 70 years. Most common in females over 50 (genetic predisposition). Clinical Unilateral headache, initially burning in character, becoming throbbing Usually temporal or occipital artery Lingual, facial and maxillary arteries may also become involved leading to claudication in eating and talking. Affecting vessels feel hard and tender Tongue may become ischaemic if lingual arteries involved If untreated 25% will develop visual problems secondary to central retinal artery involvement, which may be bilateral. Loss of vision may be the first clinical sign.

15. Temporal (giant cell) arteritis
Investigation
Increase ESR (60-100)
Normocytic, Normochromic anaemia
Artery biopsy:
Usually superficial temporal under LA
Giant cell lesions seen
Treatment
60-100mg prednisolone daily start before temporal artery biopsy with aim to preserve vision.
Decrease steroid dose with resolution of headache and normalization ESR (may take months or years)

16. Atypical facial pain Definition
Diagnosis of exclusion. Constant, chronic pain in the absence of identifiable organic disease. More common in female. Most patients are middle aged or elderly
Clinical
Often difficult for patients to describe symptoms
Most frequently described as deep, constant ache or burning
Does not stop patients sleeping
Does not follow anatomical patterns:
May be bilateral
Can cross midline
Infrequently move to another site
Maxilla more than mandible
Often initiated/ exacerbated by dental treatment
Examination entirely normal

17. Atypical facial pain Investigation
All imaging (including intracranial MRI), bloods, and biopsies are normal
Treatment
Often unrewarding with limited response
Tricyclic antidepressants have some effect in some patients
About 30% will respond to gabapentin
The involvement of a pain team with access to psychological therapy may help patients to manage their pain

18. Burning mouth syndrome
Definition
Burning sensation of oral mucosa, usually tongue, in absence of any identifiable clinical abnormality or cause
Epidemiology
5 per can be higher in middle aged and elderly patients. Female affected more than male.
Cause
Unknown, but abnormal factors, anxiety and stress have been implicated
Clinical
complain of dry mouth with altered or bad taste
Burning sensation affected tongue and anterior palate
May be aggravated by certain foods
usually bilateral and does not awake patient but often present on awaking
examination entirely normal

19. Burning mouth syndrome
Investigation
Full blood count
Haematinics (iron, B12, and folate)
Swab for candida
All clinical investigations, including bloods and swabs, are normal
Treatment
Reassurance: patients are often cancerophobic
Avoidance of stimulating factors
Some patients may respond to tricyclic antidepressants
Conginitive behavioural therapy may help and manage their symptoms as medical management is often disappointing