Differential Diagnosis of Craniofacial Pain

Differential Diagnosis of Craniofacial Pain Steven J. Scrivani Chief, Oral and Maxillofacial Pain Center Department of Oral and Maxillofacial Surgery Massachusetts General Hospital Adjunct Professor Craniofacial Pain and Headache Center Tufts University School of Dental Medicine Department of Public Health and Family Medicine Pain Research, Education and Policy Program Tufts University School of Medicine Research Associate Pain and Analgesia Imaging and Neuroscience (P.A.I.N.) Group Brain Imaging Center McLean Hospital Center for Pain and the Brain Children s Hospital Waltham

IHS

International Headache Society International Classification of Headache Disorders III (ICHD III-Beta) Cephalalgia, 2013 14 CATEGORIES The Primary Headaches: 1-4 The Secondary Headaches: 5-12 Painful Cranial Neuropathies, Other Facial Pains and Other Headaches: 13-14 Appendix [220-259 Diagnoses]

The Primary Headaches (1-4) 1. Migraine *without aura *with aura 2. Tension-type headache 3. Trigeminal autonomic cephalalgias 4. Other primary headaches

The Secondary Headaches (5-12) 5. Attributed to trauma or injury to the head and/or neck 6. Attributed to cranial or cervical vascular disorder 7. Attributed to non-vascular intracranial disorder 8. Attributed to a substance or its withdrawal 9. Attributed to infection 10. Attributed to disorder of homeostasis 11. HA or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 12. Attributed to psychiatric disorder

Painful Cranial Neuropathies and Other Facial Pains (13)

Differential Diagnosis of Craniofacial Pain What is It Really??

COMMON THINGS OCCUR COMMONLY Common presentation of a common disorder Unusual presentation of a common disorder Common presentation of an unusual disorder Unusual presentation of an unusual disorder Rare presentation of a rare disorder

Craniofacial Conditions Dentoalveolar Pathology *pulpal *periodontal Odontogenic and Non-odontogenic Pathology Primary headache Temporomandibular Disorders Oral Mucous Membrane Disease Oral Manifestations of Systemic Disease Neuropathic Pain (Persistent Idiopathic Facial Pain) Trigeminal Neuralgia Postherpetic Neuralgia Burning Mouth/Tongue Disorder

Where do we start??

It is more important to know what sort of person has a disease than to know what disease a person has. Don t touch the patient state first what you see; cultivate your powers of observation Sir William Osler, M.D. When in doubt, talk to your patient and actually touch them. JJ Salerno, M.D. SJ Scrivani

Pain Diagnosis A cluster of symptoms and signs Pattern recognition Raymond J. Maciewicz, M.D., Ph.D.

Diagnostic Medical Evaluation Chief complaint History of present illness Past medical history Review of systems Physical examination Diagnostic studies Assessment/Differential diagnosis Plan

PAIN HISTORY Location Timing Duration Quality Intensity Radiation Exacerbates?? Alleviates?? Neurosensory abnormalities Motor deficit Autonomic findings

International Headache Society International Classification of Headache Disorders III (ICHD III-Beta) Cephalalgia, 2013 14 CATEGORIES The Primary Headaches: 1-4 The Secondary Headaches: 5-12 Painful Cranial Neuropathies, Other Facial Pains and Other Headaches: 13-14 Appendix [220-259 Diagnoses]

The Primary Headaches (1-4) 1. Migraine *without aura *with aura 2. Tension-type headache 3. Trigeminal autonomic cephalalgias 4. Other primary headaches

TACs Cluster headache Episodic cluster headache Chronic cluster headache Paroxysmal hemicrania Episodic paroxysmal hemicrania Chronic paroxysmal hemicrania (CPH) Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT) Short-lasting Unilateral Neuralgiaform headache with cranial Autonomic symptoms (SUNA) Hemicrania Continua

The Secondary Headaches (5-12) 5. Attributed to trauma or injury to the head and/or neck 6. Attributed to cranial or cervical vascular disorder 7. Attributed to non-vascular intracranial disorder 8. Attributed to a substance or its withdrawal 9. Attributed to infection 10. Attributed to disorder of homeostasis 11. HA or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 12. Attributed to psychiatric disorder

Red Flags in the Headache History HA accompanied by unconsciousness First-worst HA (appearing suddenly) HA accompanied with neurological abnormalities during and/or after the HA HA associated with fever or stiff neck HA developing after 50 years of age A change in characteristic response to previous treatments of HA HA associated with alterations in behavior and personality HA initiated by Valsalva maneuver

SNOOPP for Secondary HA David Dodick, MD Mayo Clinic, Scottsdale, AZ Systemic symptoms Secondary risk factors underlying disease Neurological symptoms or abnormal signs Onset: sudden, abrupt, or split-second ( First, Worst ) Older: new onset and progressive HA, especially in older-age group Pattern change Previous HA history: attack frequency, severity, or clinical features

Adapted from RA Purdy, M.D. It should be easy to separate primary and secondary headaches by diagnosis. It should be easy once this is done to perform tests to rule out the secondary headaches. Since it is not easy, what is the problem. Atypical Features Need more history and physical examination!!

Headache attributed to head and/or neck trauma (5.1-7) 5.1 Acute post-traumatic HA moderate or severe head injury mild head injury 5.2 Chronic post-traumatic HA 5.3 Acute HA attributed to whiplash injury 5.4 Chronic HA attributed to whiplash injury 5.5 HA attributed to traumatic intracranial hematoma 5.6 HA attributed to other head and/or neck trauma 5.7 Post-craniotomy HA

Postconcussion Syndrome (PCS) PCS refers to a large number of signs and symptoms that may occur alone or in combination, usually after mild head injury. Concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness. LOC does not have to occur for PCS to develop. Headache, dizziness, blurred vision, fatigue, irritability, anxiety, insomnia, loss of concentration and memory, depression and noise sensitivity are the most common complaints.

Post-traumatic Headaches 30% - 90% of persons who are symptomatic after MHI. Paradoxically, HA prevalence and lifetime duration is greater in those that have MHI compared with those who have more severe head trauma. More common in those who have a history of HA. Many patients have more than 1 type of HA. Neck injuries commonly accompany head trauma and can produce HAs. HAs are commonly associated with whiplash injuries. Although not part of PCS, HAs associated with subdural and epidural hematomas also occur.

Whiplash-Related Injuries Possible Symptoms (1) Headache (2) Neck pain (3) Reduced cervical range of motion (4) Face and jaw pain (5) Autonomic dysfunction (6) Visual disturbances (7) Dizziness (cervical vertigo) Management depends upon the nature of the complaint Commonly seen after motor vehicle accident with associated TBI

Headache and Facial Pain: Carotid Dissection H/A as initial symptom 47% 15% thunderclap 85% gradual Severity 75% severe 25% mild/moderate H/A present at any time 68-92% Neck pain only 19% Orbital pain alone 10-17%

Post-Craniotomy Headache and Facial Pain

Headache attributed to cranial or cervical vascular disorders (6.1-7) 6.1 Ischemic stroke or TIA 6.2 Non traumatic intracranial hemorrhage 6.3 Unruptured vascular malformation 6.4 Arteritis 6.5 Carotid or vertebral artery disorder 6.6 Cerebral venous thrombosis 6.7 Other intracranial vascular disorders (CADASIL, MELAS, pituitary apoplexy)

Thunderclap Headache High-intensity headache of abrupt onset. Abrupt onset, reaching maximum intensity in <1 minute. Frequently associated with serious vascular intracranial disorders, particularly subarachnoid hemorrhage. It is mandatory to exclude this and a range of other such conditions including intracerebral hemorrhage, cerebral venous thrombosis, unruptured vascular malformation (mostly aneurysm), arterial dissection (intra- and extracranial), reversible cerebral vasoconstriction syndrome (RCVS) and pituitary apoplexy.

Vasculitides with Headache & Facial Pain Polyarteritis nodosa group Hypersensitivity angiitis group Drug-induced angiitis Cryoglobulinemic vasculitis Infection-related vasculitis Paraneoplastic vasculitis Granulomatoses Wegeners granulomatosis Lymphomatoid granulomatosis Lethal midline ganuloma Sarcoidosis Giant cell arteritis Temporal arteritis Takayasu arteritis Connective tissue disorders SLE RA Scleroderma SS Bechet s syndrome Cogan syndrome Mixed CT disease

Temporal Arteritis Age > 50 years Headache, neck pain, jaw claudication, scalp tenderness, facial pain, visual loss Thickened, nodular, pulseless superficial temporal artery Headache is mild to severe, and of acute or gradual onset; the patient is typically without a history of HA or deviation from his or her chronic HA pattern (New) Associated with polymyalgia rheumatica, especially in elderly patients

Temporal Arteritis Blood studies elevated ESR, CRP Others Temporal artery biopsy false negatives due to skipped lesions (bilateral biopsies) Treatment with corticosteroids

Symptom Prevalence 90% - headache 69% - tender temporal artery 67% - jaw or tongue claudication (pain on chewing or swallowing) 55% - weight loss 48% - polymyalgia rheumatica 40% - absent TA pulse 40% - visual symptoms 21% - joint pain 21% - fever 14% - peripheral neuropathy 7% - TIA or stroke

Niederkohr et al Ophthal 2005;112:744 Hayreth et al Amer J Ophthal 1997;123:285 Symptoms with positive diagnostic likelihood ratios: Jaw claudication Temporal artery abnormality Diplopia Neck pain Weight loss Headache

Rozen TD: Brief sharp stabs of head pain and giant cell arteritis. Headache. 50:1516-1519, October 2010.

Headache and Facial Pain: Carotid Dissection H/A as initial symptom 47% 15% thunderclap 85% gradual Severity 75% severe 25% mild/moderate H/A present at any time 68-92% Neck pain only 19% Orbital pain alone 10-17%

Headache attributed to non-vascular intracranial disorder (7.1-9) 7.1 High CSF pressure (idiopathic, metabolic, toxic, hydrocephalus) 7.2 Low CSF pressure (spontaneous, PDP, fistula) 7.3 Non-infectious inflammatory disorder 7.4 Intracranial neoplasm 7.5 Intrathecal injection 7.6 Epileptic seizure 7.7 Chiari malformation 7.8 Syndrome of Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) 7.9 Other

Idiopathic Intracranial Hypertension Pseudotumor Cerebri Primarily in young, obese women of childbearing age Headache (CDH), transient visual obscurations (seconds), pulsatile intracranial noises, double vision Typically visual acuity and color are preserved, but optic nerve-related visual field defects are present in > 90% of patients (e.g., enlarged blind spots, generalized constriction, and inferior nasal field loss) Several predisposing factors have been identified, including the use of oral contraceptives, anabolic steroids, tetracycline, and vitamin A

Headache attributed to a substance or its withdrawal (8.1-4) 8.1 HA induced by acute substance use or exposure NO donor-induced PDE inhibitor-induced Alcohol induced HA induced by food components and additives Cocaine induced Cannabis induced 8.2 Medication overuse HA (MOH) 8.3 HA as an adverse event attributed to chronic medication (for other conditions) 8.4 HA attributed to substance withdrawal Caffeine-withdrawal Opioid-withdrawal Estrogen-withdrawal Ergot-withdrawal Triptan-withdrawal

Medication Overuse Headache Analgesic use > 15 days month All others > 10 days Worsening of headache 3-4 hours after analgesic wears off Withdrawal phenomena, where patients experience an escalation in symptoms after the discontinuance of medication Other pharmacologic and nonpharmacologic therapies are rendered essentially ineffective in the face of overuse syndromes

Common Medications Associated With MOH Ergots Triptans NSAIDs Combination analgesics Opioids

Opioid - induced hyperalgesia (OIH) in patients using opioid treatment for chronic myofascial pain A case series Georgios Kanavakis, Brijesh Chandwani, Noshir Mehta, Steven Scrivani 5 patients who had undergone chronic opioid treatment for myofascial pain presented hyperesthesia/dysesthesia and hyperalgesia on palpation of the face and head muscles.

Headache attributed to infection (9.1-4) 9.1 - Headache attributed to intracranial infection (bacterial meningitis, lymphocytic meningitis, encephalitis, brain abscess, subdural empyema 9.2 - Headache attributed to systemic infection (bacterial infection, viral infection, other systemic infection 9.3 - Headache attributed to HIV/AIDS 9.4 - Chronic post-infection headache (Chronic postbacterial meningitis headache)

Infections Herpes zoster (VZV) Mumps Rubulavirus (parmyxovirus) Lyme disease (Borrelia) spirochete bacterium Babesiosis protozoan parasite

Headache attributed to disorders of homeostasis (10.1-7) 10.1 Headache attributed to hypoxia and/or hypercapnia 10.2 Dailysis headache 10.3 Headache attributed to arterial hypertension 10.4 Headache attributed to hypothyroidism 10.5 Headache attributed to fasting 10.6 Cardiac cephalalgia 10.7 Headache attributed to other disorders of homeostasis

Sleep Apnea Headache These are recurrent headaches, >15 days/month Bilateral, pressing No associated symptoms Each headache resolves in 30 minutes Sleep apnea demonstrated by polysomnography Headache present upon awakening Headache ceases within 72 hours and doesn t recur after sleep apnea treated

Headache Related to Arterial Hypertension Mild or moderate hypertension does not cause headache Various disorders that lead to paroxysmal, abrupt, severe elevations are associated with headaches Pheochromocytoma Hypertensive crises (with or without encephalopathy) Pre-eclampsia and eclampsia

Cardiac Cephalalgia This is a headache that occurs during acute myocardial ischemia Headache begins in close proximity to onset of vigorous exercise Headache subsides with rest or anti-anginal treatment Reports have occurred while at rest Headache associated with nausea Not precipitated by valsalva Often associated with face/jaw pain

Headache or facial pain attributed to disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures (11.1-8) 11.1 Cranial bones 11.2 Neck Cervicogenic headache 11.3 Eyes 11.4 Ears 11.5 Sinus disorders ( Sinus headache ) 11.6 Teeth, jaws or related structures 11.7 TMJ disorders (TMD)

Disorder of Cranial Bones Most disorders of the skull not associated with headache Exceptions: Osteoarthritis (TMJ, cervical spine), Paget s disease, multiple myeloma Headache can result from skull lesions that: involve periosteum, are rapidly expansive, are aggressively osteoclastic, have an inflammatory component Inflammatory/infectious processes of mastoid and petrous portion of temporal bone cause headaches

Craniofacial Bones Paget s disease Fibrous dysplasia McCune-Albright syndrome Ossifying fibroma Multiple myeloma Osteoradionecrosis of the jaws Medication-related osteonecrosis of the jaws

Pain Sensitive Structures and Tissues in the Neck Zygapophyseal joints (facet joints) C 1-2, C 2-3, C 3-4 Nerve roots, rami and branches Dorsal ramus of C 2 (Greater Occipital Nerve) Dorsal ramus of C 3 (Third Occipital Nerve) Synovial tissue Intervertebral discs Muscles/Tendon insertions Blood vessels **Referred pain patterns

Activation of the TNC May Result in Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Network

Cervical Spine Pain Syndromes Strain/sprain Myofascial pain syndrome Facet syndrome/medial branch Foraminal stenosis Degenerative disorders Intervertebral disc disorders Neuralgic/neuropathic

Neck-Tongue Syndrome Lance JW, Anthony M: Journal of Neurology, Neurosurgery & Psychiatry. 43(2):97-101, 1980. Acute unilateral occipital pain precipitated by sudden movement of the head, usually rotation A sensation of numbness in the ipsilateral half of the tongue Temporary subluxation of the lateral A-A joint Numbness of the tongue arises because of impingement or stretching of the ventral C2 ramus against the edge of the subluxed articular process. Proprioceptive afferents from the tongue pass from the hypoglossal nerve into the ventral C2 ramus. Causes: RA of the cervical spine, congenital joint laxity, hypomobility of the contralateral lateral A-A joint

Headache or facial pain attributed to disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures (11.1-8) 11.3 HA attributed to disorder of eyes Acute glaucoma Refractory errors Latent or manifest squint Ocular inflammatory disorder Red or inflamed eye White or quite eye

Red Flags for a Patient with Eye Pain New visual acuity defect, color vision defect, or visual field loss Relative afferent pupillary defect Extraocular muscle abnormality, ocular misalignment, or diplopia Proptosis Lid retraction or ptosis Conjunctival chemosis, injection or redness Corneal opacity Hyphema or hypopyon Iris irregularity Nonreactive pupil Fundus abnormality Recent ocular surgery (< 3 months) Recent ocular trauma

Headache & Facial Pain Syndromes with Predominant Ophthalmologic Findings Carotid artery disease Orbital inflammatory pseudotumor Increased ICP (pseudotumor cerebri) Intracranial hemorrhage and stroke Intracranial A-V malformation Tolosa-Hunt syndrome Raeder s paratrigeminal syndrome Gradenigo s syndrome Postherpetic neuralgia

Orbital Inflammatory Pseudotumor Idiopathic orbital inflammation Eye pain typically with other orbital findings (proptosis, injection, chemosis or ophthalmoplegia) The inflammatoty process may be confined to one or multiple extraocular muscles (orbital myositis), the trochlea (trochleitis), the lacrimal gland (dacryoadenitis) or nonspecifically affect the entire orbit OIP May be unilateral or bilateral Imaging (CT or MRI) typically shows inflammation, enlargement, and pathological contrast enhancement involving orbital structures Orbital biopsy may be required to exclude other causes

Pain in or Around the Eye Quite Eye & Normal Exam Cluster headache and cluster-tic syndrome Paroxysmal hemicrania SUNCT/SUNA syndrome Migraine and tension-type headache Ice-pick HA/Ice cream HA/valsalva HA Trigeminal neuralgia Sinus disease (acute) Teeth, jaws (TMD) Carotid disease Temporal arteritis Eye pain, headache and lung cancer

Headache and Facial Pain: Carotid Dissection H/A as initial symptom 47% 15% thunderclap 85% gradual Severity 75% severe 25% mild/moderate H/A present at any time 68-92% Neck pain only 19% Orbital pain alone 10-17%

Ear Throat Ext/middle ear Carotid dissection TMD (joint or muscle) Laryngeal N. Ramsey-Hunt syn. Myogenous Parotid gland Parotid gland Myogenous TMD Carotid Submandibular gland Lymphadenopathy Geniculate N. Glossopharyngeal N. Glossopharyngeal N. Eagle syndrome Eagle syndrome Ernst syndrome Ernst syndrome Carotidynia Carotidynia

Eagle WW. Elongated styloid process. Report of two cases. Arch Otolaryngol. 1937;25:584 587. Eagle WW. Elongated styloid process. Arch Otolaryngol. 1948;47:630 640. Eagle WW. Elongated styloid process, symptoms and treatment. Arch Otolaryngol. 1958;67:172 176. Described it as atypical facial neuralgia and reported that it has various symptoms: like feeling of a foreign body lodged in the throat, difficulty and pain during swallowing, throat pain, pain on turning the head, pain in infraorbital, infratemporal, ear and occipital areas, pain on wide opening of mouth, headache, tinnitus and vertigo

Now This Is Eagle Syndrome!!!!

Headache and Facial Pain Due to Nasal and Paranasal Sinus Disease Sinus Headache

Odontogenic Pain Diagnosis Pulpitis Periodontal Cracked tooth Dentinal Diagnostic Features Spontaneous and/or evoked deep/diffuse pain in compromised dental pulp. Pain may be sharp, throbbing, or dull. Localized deep continuous pain in compromised periodontium (eg, gingiva, periodontal ligament) exacerbated by biting or chewing. Spontaneous or evoke brief sharp pain in a tooth with history of trauma or restorative work (eg, crown, root cannal). Brief, sharp pain evoked by different kinds of stimulus to the dentin (eg, hot or cold drinks). Diagnostic Evaluation Look for deep caries and recent or extensive dental work. Pain provoked/exacerbated by percussion, thermal or electric stimulation of affected tooth. Dental x rays helpful (periapical). Tooth percussion over compromised periodontum provokes pain.look for inflammation or abscess (eg, periodontitis, apical dental x rays helpful (bitewings, periapical). Presence of tooth fracture may be detectable by x ray. Percussion should elcit pain. Dental x rays are helpful (periapical taken from different angles). Exposed dentin or cementum due to recession of periodontum. Possible erosion of dentinal structure. Cold stimulation reproduce pain. Treatment Medication: NSAIDs, nonopiate analgesics. Dentistry: remove carious lesion, tooth restoration, endodontic treatment or tooth extraction. Medication: NSAIDs, non opiate analgesics, antibiotics, mouthwashes. Dentistry: drainage and debridement of periodontal pocket, scaling and root planning, periodontal surgery, endodontic treatment or tooth extraction. Medication: NSAIDs, nonopiate analgesics. Dentistry: depends on level of the tooth fracture restoration; treatment, or extraction of the tooth. Medication: mouthwash (fluoride), desensitizing toothpaste. Dentistry: fluoride or potassium salts, tooth restoration, endodontic treatment. Patient education, diet, tooth brushing force and frequency, proper tooth paste.

Odontogenic and Nonodontogenic Disorders Odontogenic Cysts & Tumors Nonodontogenic Cysts and Tumors Metabolic Bone Disease Maetastatic Bone Disease Neurogenic Tumors Vascular Lesions Hemangiomas and Vascular malformations

Common Painful Mucosal Conditions

Salivary Gland Disease Inflammatory Non-inflammatory Infectious Obstructive Immunologic (Sjogren s Syndrome) Tumors Others (Red herrings)

Temporomandibular Disorders A subgroup of craniofacial pain disorders that encompass a group of musculoskeletal and neuromuscular conditions that involve: 1. The temporomandibular joint 2. The masticatory muscles 3. Associated head and neck structures de Leeuw R, Klasser GD (ed.): Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. The American Academy of Orofacial Pain, 5 th Edition, Quintessence Publishing Co., Inc., 2013.

Temporomandibular Disorders Masticatory muscle disorders TM Joint articular disorders Congenital and developmental disorders Chronic mandibular hypomobility Hypermobility (subluxation/dislocation)

Temporomandibular Joint Articular Disorders 1. Congenital or developmental Aplasia Hypoplasia Hyperplasia 2. Joint Pain Arthralgia Arthritis 3. Joint Disorders Disc-condyle Complex Disorders Other Hypomobility Disorders Adhesions, Ankylosis Hypermobility Disorders Subluxation, Dislocation

4. Joint Diseases Temporomandibular Joint Articular Disorders Degenerative Joint Diseases Osteo-arthritis/arthrosis Condylysis ICR Osteonecrosis Systemic Arthritides RA, AS, Rieter s, etc. Neoplasm Synovial Chondromatosis 5. Fractures

Masticatory Muscle Disorders 1. Muscle Pain Limited to the Orofacial Region Myalgia Tendonitis Myositis Spasm 2. Myofibrotic Contracture 3. Hypertrophy 4. Neoplasms 5. Movement Disorders dyskinesia/dystonia 6. Masticatory Muscle Pain Due to Systemic/Central Disorders

Headache attributed to psychiatric disorder (12.1-2) 12.1 Somatization disorder 12.2 Psychotic disorder

Psychological Disorders and Chronic Pain Why? 1. High prevalence of psychological comorbidities among patients with chronic pain 2. Presence of chronic pain may cause emotional distress and exacerbate premorbid psychological disorders 3. Emotional problems may increase perceived pain intensity, disability and perpetuate dysfunction 4. Unrecognized and untreated psychological distress may interfere with successful treatment of chronic pain Adapted from Turk, D.

Psychological Conditions Associated with Chronic Pain Mood Disorders Anxiety Disorders Somatoform Disorders Personality Disorders Other Conditions

Substance abuse and pain co-occur 3-19% of chronic pain patients suffer from addictive or substance abuse disorders Fishbain et al (1992) Haller & Butler (1991) Fishbain et al (1999) Rafii et al (1990) Bernt et al (1993) Chabal et al (1998) Cowan et al (2003)

Major Depression and Pain 15%-100% (mean=65%) of depressed patients complain of pain [13 prevalence studies in psychiatric settings] 41 studies on prevalence of depression and chronic pain: 23% in OB-GYN clinics, 27% in PC, 35% in psych clinics, 38% in pain clinics, 52% in rheumatology clinics and 78% in dental/facial clinics Blair MJ, Robinson RL, Katon W, et al: Depression and pain comorbidity: a literature review. Arch Intern Med. 163:2433-2445, 2003.

Chronic Pain and Abuse Domino and Haber 66% of headache patients reported a history of physical or sexual abuse Drossman, et al 44% of females referred to a GI clinic Toomey, et al 53% of pelvic pain patients Taylor, et al 65% of their fibromyalgia group

Chronic Facial Pain Traumatic Events in Childhood Pain No pain Parental Alcohol Abuse 49% 14% Parental Illness 23% 4% Separated from Parent 27% 24% Sexual Abuse 4% 0% Multiple Events 51% 20% Bouckoms, Keith, et al: MGH, 1991.

Childhood Abuse, Depression and Chronic Pain 201 consecutive patients with chronic pain 68% female, mean age 38 years 26% low back pain 19% craniofacial pain 25% pain in other regions 28% pain in more than 3 sites *Patients with a history of both physical and sexual abuse in childhood had more depression. *The influence of type of pain on depression was not significant Goldberg RT, 1994

Pain Associated with Past Abuse Childhood abuse is associated with five types of pain Back Pain Headaches & Facial Pain Pelvic Pain Irritable Bowel Syndrome Fibromyalgia Many of these types co-occur Kendall-Tackett, K: Health Consequences of Abuse in the Family, American Psychological Association, 2004.

Painful Cranial Neuropathies and Other Facial Pains (13)

Painful cranial neuropathies and other facial pains 13.1 Trigeminal neuralgia 13.1.1 Classical trigeminal neuralgia 13.1.1.1 Classical trigeminal neuralgia, purely paroxysmal 13.1.1.2 Classical trigeminal neuralgia with concomitant persistent facial pain 13.1.2 Painful trigeminal neuropathy 13.1.2.1 Painful trigeminal neuropathy attributed to acute Herpes zoster 13.1.2.2 Post-herpetic trigeminal neuropathy 13.1.2.3 Painful post-traumatic trigeminal neuropathy 13.1.2.4 Painful trigeminal neuropathy attributed to multiple sclerosis (MS) plaque 13.1.2.5 Painful trigeminal neuropathy attributed to space-occupying lesion 13.1.2.6 Painful trigeminal neuropathy attributed to other disorder

13.2 Glossopharyngeal neuralgia 13.3 Nervus intermedius (facial nerve) neuralgia 13.4 Occipital neuralgia 13.5 Optic neuritis 13.6 Headache attributed to ischemic ocular motor nerve palsy 13.7 Tolosa-Hunt syndrome 13.8 Paratrigeminal oculosympathetic (Raeder s) syndrome 13.9 Recurrent painful ophthalmoplegic neuropathy 13.10 Burning mouth syndrome (BMS) 13.11 Persistent idiopathic facial pain (PIFP) 13.12 Central neuropathic pain Central neuropathic pain attributed to multiple sclerosis (MS) Central post-stroke pain (CPSP)

TRIGEMINAL NEURALGIA Trigeminal Neuralgia Equivalents 1. Paroxysmal pain 2. Trigger areas 3. Unilateral 4. No sensory deficit 5. Restricted to the distribution of the trigeminal nerve 6. No obvious source of pathology

Trigeminal Neuralgia Is Not very common (5 per 100,000 population annually). Typically in persons around age 60. More often in women. More often on the right side of the face. More often in the region around the mouth and jaws.

CHARACTERISTICS OF PATIENTS Scrivani SJ, Mathews ES, Keith DA, Kaban LB: 1997 SCRIVANI **COMBINED AVERAGE AGE 61.5 65 (RANGE:41-95) SEX 69%FEMALE 62%FEMALE SIDE OF FACE 58%RIGHT 60%RIGHT DIVISION INVOLVED: V-1 0 1% V-2 13% 16% V-3 38% 15% V-1, V-2 8% 15% V-2, V-3 33% 40% V-1, V-2, V-3 4% 13% **Tew JM, van Loveren H: 1995.

Classification of TN Classical or Primary TN Idiopathic TN type 1 TN type 2 (Burchiel K: 2005) Symptomatic or Secondary TN Associated with another disease process

Burchiel K: Neurosurgery, 2003. Diagnosis Trigeminal neuralgia Type 1 Trigeminal neuralgia Type 2 History Spontaneous onset > 50% episodic pain > 50% constant pain Trigeminal neuropathic pain Trigeminal deafferentation pain Symptomatic trigeminal neuralgia Postherpetic neuralgia Atypical facial pain * * Cannot be diagnosed by history alone Trigeminal injury Unintentional, incidental trauma Intentional deafferentation Multiple sclerosis Trigeminal Herpes zoster outbreak Somatoform pain disorder

Structural Lesions and Facial Pain MS Plaques CP Angle Tumors Vascular Malformations Schwannomas Chiari Malformations Midbrain Lesions Pontine Hemorrhage Skull Base Tumors SC Carcinomas Salivary Gland Tumors Oral Cancers Carotid/Vertebral Disease

Facial Pain and Cerebellopontine Angle Tumors Nguyen M, Maciewicz R, et al: Clin J Pain, 1986. 1. Meningiomas: variable pattern of cranial nerve V, VII, VIII deficits 2. Acoustic neuromas: cranial nerve VII deficits 3. Epidermoid tumors: few signs or symptoms other than facial pain

Comprehensive Study of Diagnosis and Treatment of Trigeminal Neuralgia Secondary to Tumors Cheng TM, Cascino TL, Onofrio BM: Neurology, 1993. 1976-1990: 5,058 patients TN= 2,972 Tumors in 296/2,972 (9.95%) >Meningioma >Schwannoma >Pituitary tumors >Others: glioma, lymphoma, arachnoid cyst, SCC Only 2% had classical TN findings 47% developed neurological deficits (avg. 6.3 yrs)

Chronic Neurogenic Facial Pain & Tumors Scrivani SJ, Maciewicz RJ, Keith DA, Mathews ES: JOMS, 1997 Mathews ES, Scrivani SJ: Mt Sinai J Med, 2000. 1992-1996 575 patients with chronic neurogenic facial pain 360 (63%) - initial diagnosis of TN 8.4% had structural pathology on MRI

The Spectrum of Pain in Herpes Zoster Prodrome onset Typically 1 wk. Rash onset Rash healed 2 4 wks. Can be years Pain cessation Acute Pain Postherpetic neuralgia (PHN) 1 mo. 3 mo. 6 mo.

PHN: Clinical Presentation Constant baseline pain (burning, aching) Spontaneous, intermittent pain (lancinating, jabbing) Allodynia (mechanical, cold/warm) Sensory abnormalities (itching, numbness, tingling) Sensory deficits (absent or diminished thermal, tactile) Skin pigmentation changes and/or scarring

Neuropathic Facial Pain Old & New Names Atypical Facial Pain (AFP) Atypical TN Atypical Odontalgia ( Persistent toothache ) Deafferentation Pain Syndrome Phantom Tooth Syndrome Sympathetically Maintained Pain Painful Post-traumatic Trigeminal Neuropathy Persistent Idiopathic Facial Pain Chronic Regional Pain Syndrome I & II

Of 770 articles retrieved and reviewed, 10 met inclusion criteria, and nine had data on both odontogenic and nonodontogenic causes of pain. A total of 3,343 teeth were enrolled within the included studies and 1,125 had follow-up information regarding pain status. We identified 48 teeth with nonodontogenic pain and estimated a 3.4% (95% confidence interval, 1.4%-5.5%) frequency of occurrence.

Chronic Neuropathic Facial Pain Trigeminal Neuropathic Pain Disorder IHS Idiopathic Persistent Facial Pain Complex, multi-factorial process Regional Pain is the primary symptom Additional symptoms which occur together; the sum of signs of any morbid state - a Syndrome CRPS type I and II

Tolosa-Hunt Syndrome Episodic unilateral orbital or retro-orbital pain (average of 8 weeks, if untreated) Ophthalmoplegia (CN II, III, IV, VI) simultaneously or within the first 2 weeks Prompt (within 72 h) to treatment with steroids Other pathological conditions excluded with examination and neuroimaging Thought to be due to a nonspecific granulomatous inflammatory infiltrative process with no obvious specific pathological trigger in the region of the posterior superior orbital fissure, orbital apex or cavernous sinus

Raeder s Paratrigeminal Syndrome Paratrigeminal oculo-sympathetic syndrome (POSS) Sympathetic dysfunction (miosis, ptosis or both), but with normal forehead sweating (compared to Horner s syndrome) First division trigeminal neuropathic pain or sensory loss Anatomical localization points to the middle cranial fossa medial to the trigeminal ganglion and lateral to the anterior clinoid process Neuroimaging is necessary and important, and if negative, should be repeated over a period of time to determine if an underlying abnormality had been missed This syndrome is not specific to any pathological entity

Burning Mouth/Tongue (Oral Burning) Neuropathic Pain Syndrome + Taste Abnormality??

Burning Mouth Oral burning pain Dysesthetic qualities similar to other neuropathic pain disorders Dorsal tongue, anterior palate, lips and gingival tissues (alone or in combination) Usually bilateral Associated with jaw pain, tooth pain, jaw tightness, headache, neck and shoulder pain, difficulty speaking and swallowing, subjective dry mouth and taste changes