OROFACIAL PAIN AND HEADACHES NOTES

OROFACIAL PAIN AND HEADACHES

Introduction:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue
damage or described in terms of such damage.

What is orofacial pain means?

Classification:

A) Acute:

Dental pain due to dental caries/ broken filling /abraded tooth

Periodontal /Gingival origin

B) Chronic:

Neurovascular: Neuropathic pain:

1. Migraine 1. Posttraumatic neuropathy
2. Trigeminal Autonomic Cephalgias 2. Burning mouth syndrome
 Cluster Headache, 3. Trigeminal Neuralgia
 Paraoxysmal hemicranias 4. Post herpetic neuralgia
 SUNCT 5. Glossopharyngeal Neuralgia
 SUNA
 Hemicrania continua

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 OROFACIAL PAIN AND HEADACHES NOTES

NEUROPATHIC PAIN

Trigeminal Neuralgia(TN)

 It is an excruciating ,short lasting, unilateral facial pain.

 Etiology: Primary: compression of the trigeminal nerve root by a vascular malformation
Secondary: secondary to tumours/cyst /viral infection/trauma/systemic disease like multiple
sclerosis
 Paroxysmal, excruciating pain in trigeminal dermatomes commonly both maxillary and
mandibular branches of trigeminal nerve .Can affect all three branches-Maxillary, Mandibular
and Ophthalmic branch.

Clinical Features:

 The pain is Paroxysmal , Shooting, sharp, piercing, stabbing or electrical

 Pain episodes are identical in location, duration and intensity
 TN is characterized by spontaneous remissions lasting for few weeks to months
 Attacks begin and end abruptly lasting from a fraction of a second to 2 minutes
 Pain paroxysms are usually accompanied by spasm of ipsilateral facial muscles( tic Douloureux)
 Pain is precipitated by light ,innocuous touch- trigger areas. These trigger areas are distributed
along the nerve branch. The common trigger factors are noise, light and stress, touch

Investigation: CT/MRI

Treatment:

Medical mgt:

Carbamazeoine 100-200mg twice daily

Oxycarbamazepine 300mg TID
Baclofen 5-10mg TID
Gabapentin 200-300mg twice daily
Lamotrigine 25 mg 1-2/day

Surgical mgt:

Neurectomy at peripheral level/ Ganglion level/Trigeminal root level.

Percutaneous Trigeminal Rhizotomy
Microvascualr decompression
Gamma knife

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 OROFACIAL PAIN AND HEADACHES NOTES

Glossopharyngeal Neuralgia

 Glossopharyngeal nerve has two branches- auricular( tymphanic ) and pharyngeal branch.
Henceforth the pain radiates to inner ear or angle of mandible and may include eye, nose,
Maxilla shoulder or tip of tongue.
 Bilateral pain

Clinical features:

 Paroxysmal, unilateral severe pain – sharp , stabbing , shooting or lacinating pain.

 Patient feel scratching or foreign body sensation in the throat.
 Attacks lasts from few seconds to minutes
 Trigger areas- tonsillar and posterior phargynx and has refractory period.
 Swallowing,chewing ,clearing the throat and rubbing the ear can activate
 These can induce uncontrollable coughing, seizures ,syncope,bradycardia

Investigations: MRI/Electrocardiogram

Treatment:

Carbamezepine
Baclofen
Gabapentin
Oxycarbamazepine
Phenytoin
Lamotrigine

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 OROFACIAL PAIN AND HEADACHES NOTES

Post Herpetic Neuralgia

Acute Herpes Zoster(Shingles) is a reactivation of latent varicella virus infection that can occur after
decades of primary infection. The Herpes zoster infection affects the dorsal root ganglion and therefore
causes vesicular eruption along the dermatome.it can affect all the 3 branches. The ophthalmic branch –
affected- keratitis-blindness. The vesicles are unilateral and may present intraorally when the
mandibular or maxillary branches are affected. The pain that affects after the herpetic eruptions rupture
out is termed as postherpetic neuralgia.

Shingles(Herpes-primary)

Herpes zoster infection

( vesicular eruptions along the dermatome-unilateral)

Lesions rupture and form a rash

Develops a neuralgic type of pain

Post herpetic Neuralgia

Clinical Features:
 Moderate background pain to excruciating ,superimposed lacinating pains.Pain is burning,
throbbing, stabbing, shooting or sharp.
 Itching is very common. Red /purple scars usually allodynia and hyperalgesia.
 Pain precedes typical vesicular eruption by <7 days usually 2-3 days.
 Pain intensity of greater than 5/10.Can persist for 3 to 6 months.
 Very rarely pain occurs without rash- Zoster sine herpete

Investigation:
Identification of viral DNA by employing PCR

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CT/MRI

Treatment:
 Ophthalmic PHN –worst prognosis
 Tricyclic antidepressants, gabapentin, pregablin, opiods, tramadol and Topical lidocaine patches
 Invasive therapies like epidural and intrathecal steroids anbe given.
 Surgical intervention of doral root zone lesion is done
 Prevention can be done by vaccination

BURNING MOUTH SYNDROME

 This is the condition called stomatodynia and characterized by burning mucosal pain with no
significant physical signs.
 Common in postmenopausal women

Clinical Features:

 The primary location of burning complaint is the tongue-anterior 2/3

 Other areas affected is palate,lips, gingiva
 Pain is burning or hot and intensity from mild to severe
 Spontaneous onset and lasts for months to several years
 The pain pattern is , the pain increases towards the end of the day.
 Common aggrevating factors: personal stressors, fatigue and specific food
 Altered taste sensation- metallic taste
 Dry mouth
 Hyposalivation
 Oral and perioral burning can be of local and systemic factors for a symptomatic Burning mouth
symdrome.
Local factors and diseases – Lichen planus,candiasis, allergies
Systemic factors and diseases- hormonal canges, deficiencies of vit B12,folic acid, iron , DM
Autoimmune diseases,Side effects of some medications.

Treatment:

Topical

 Clonazepam 1 mg thrice daily sucked and spat

 Topical anaesthetics

Systemic

 Paroxetine 20mg/d
 Sertraline 50mg/d

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 OROFACIAL PAIN AND HEADACHES NOTES

 A combination of alpha lipoic acid 600mg/d and gabapentin 300mg

 Clonazepam 0.5mg/d

PAINFUL POSTTRAUMATIC TRIGEMINAL NEUROPATHY(PTTN)

Some patients develop chronic pain following negligible nerve trauma such as root canal therapy or
injury to nerve bundles such as fractures, implant surgery, orthognathic surgery, third molar extractions.

Patient complaints of tongue dyesthesia after injury, persistant pain after successful RCT= Neuropathic
pain=PTTN

Clinical features:

 Presence and duration of pain in tooth

 Tenderness to percussion
 Female gender-common
 History of painful treatment
 The pain is unilateral and occurs at the site of injury-continuous but sometimes paroxysmal
attacks
 Moderate to severe intensity
 Positive or negative local neurological signs including sensory dysfunction-allodynia,
hyperalgesia/parathesia
 No triggers

Treatment:

Topical

 Topical Capsaicin
 Topical anaesthetics

Systemic

Imipramine, amitriptyline, gabapentin, Fluoxetine and pregablin, Opioids

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NEUROVASCULAR PAIN

Investigations: MRI

Treatment of Neurovascular pain

Migraine Abortive: Naproxen sodium and other analgesics

Triptans like eletriptan, frovatriptan

Prophylactic: Beta blockers-propranolol, Antiepileptic drugs(topiramate), TCA (

amitriptaline)

Cluster Headache Abortive: sumatriptan, Dihydroergotamine, Oxygen

Prophylactic: Verapamil, AED(Topiramate, gabapentin), Prednisolone. Lithium

Paroxysmal Indomethacin ,other NSAIDs

Hemicrania

SUNCT Lamotrigine,gabapentin, topiramate

Hemicrania Indomethacin and other NSAIDS

continua

Migraine

Neurovascular type of pain-headache

Clinical Findings:

 Migraine with aura(Common)

 Migraine without aura(classical )- no neurologic symptoms preceding headache
 Moderate to severe pulsating ,unilateral head pain aggrevated by routine activity.
 In addition, nausea,vomiting, photophobia and phonophobia are associated with headache,
Excessive thirst, Fluid retention in body,mood changes, constipation,diarrhea

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 Duration lasts for 2-4 hrs. Relieves after sleep

 With Aura, patient has premonitory symptoms as visual scotomas and fortification Spectra,
parathesias, muscle weakness.
 After the headache- postdrome period- were patient feels like wash off, tired ,irritable and
listless.

Mgt: refer table

Tension type Headaches

 Bilateral headache-tight band around the head tightness and pressure with beginning in
morning and persist .
 No vomiting and nausea

Treatment:

NSAIDS

Acetminophen
Aspirin
Diclofenac
Ibuprofen
Naproxen sodium

Prophylactic medications
Amitriptyline
Doxepin
Nortriptyline

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Temporal /Giant cell Arteritis

 This manifests in an insidious manner with vague symptoms like malaise,weight loss, fever and
fatigue.
 The classical manifestations are fever, anaemia, headache , increased ESR.
 Symptoms of diffuse unilateral headache along with chest and jaw pain, fever and weight loss.-
progress into severity.
 Pain has pain whle hair brushing,resting the head on the pillow or wearing a hat
 Pain in the temporal and masseter muscles while chewing is a path gnomic sign of temporal
arteritis.
 ESR, hepatic enzyme levels are elevated.
 These progress leading to blindess due to involvement of ophthalmic artery

Investigation:
Biopsy of the bilateral temporal artery

Management

Glucocorticoids-Prednisolone

Cluster Headaches:

 Primary neurovascular headache

 Two types- episodic and chronic.
 Episodic- atleast two cluster phases lasting 7 to 1 yr separated by cluster free interval of one
month or longer
 Chronic- absence of periods of remissions- can transform to episodes in future

Clinical Features:
 CH –unilateral and most painful among others
 Attack lasts from 30 mins to 2 hrs and has nocturnal onset.- wake up with pain.
 Stress, allergens, seasonal changes(spring/autumn) or nitroglycerin,alcohol- triggers CH
 Periorbital pain including ipsilateral lacrimation, reddening of eyes, nasal stuffiness and nausea.
 The pain usually begins in and around eye ,temple face and neck.
Mgt:
Refer table

Chronic Paroxysmal Hemicrania/ also called as Indomethacin responsive headaches

Short lasting headache:

1. Headaches with autonomic activation( include chronic & episodic PHC, CH,SUNCT)
2. Headaches without autonomic activation

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Clinical Features:
 Rapid onset
 Severe unilateral headpain(oculofrontal region) lasting few minutes to an hr.
 Shorter attacks
 Temporal and orbital region is painful
 Episodic attacks are more frequent -5/day.
 Conjunctival injection, lacrimation, rhinorrhea, nasal stufficness,swelling of painful areas.
Mgt: refer table

SUNCT

Short lasting, unilateral, neuralgiform, headache attacks with conjunctival injection and tearing

Seen in family

Unilateral pain with autonomic symptoms

Pain may spread across the midline

Attack lasts from 5 to 600 secs and frequency of 3 to 200 daily.

Triggers – Light touch, neck movements

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