Chapter 76

### HISTORY

Facial pain can be caused by a variety of factors, including but not limited to dental pathology, trauma, multiple sclerosis, tumors or other brain lesions, temporomandibular joint (TMJ) disorders, and myofascial and psychogenic disorders. Although most of these are difficult to treat with either medical or surgical therapy, it is possible to address the underlying insult (tumor removal, resolving dental pathology, resting the TMJ with a bite block) and improve pain by eliminating the offending agent. Trigeminal neuralgia (TM) is a specific type of facial pain syndrome which can usually be clinically distinguished from these other disorders. Proper recognition of the disorder and accurate diagnosis of TN is critical, since there are numerous therapeutic options that are effective for TN but these are of limited or no clear utility for most of the other forms of facial pain. The first known report of symptoms typical of TN came from the famous physician John Locke in 1677.1 The patient described typical severe, sharp, unilateral pain of the face and lower jaw. Interestingly, the patient had teeth removed without relief. This continues to occur to this day, since minor tooth pathology may lead to dental procedures or extractions in a somewhat speculative attempt to treat facial pain that in fact is TN. Nicolas Andre coined the term “tic douloreux,” another term still in use which describes the facial contraction and contortions that often accompany the paroxysmal pain episodes of TN.2 Until early in this century, TN was still believed to involve the facial nerve because of these often seen contractions, but it has long been established that this is simply a reactive muscular contraction during the severe pain episodes.

### DIAGNOSIS

• TN is usually characterized by unilateral, paroxysmal sharp or burning pain of brief duration (seconds to minutes) in either the maxillary (V2) and/or mandibular (V3) distributions of the trigeminal nerve beginning in patients roughly 50 to 70 years of age.

• Involvement of the ophthalmic (V1) division, bilateral symptoms, and younger age of onset can happen but are rare and should suggest consideration of an alternative diagnosis.

• Undiagnosed multiple sclerosis can present with TN-like symptoms, and very young age of onset (20-40-year old) should promote further testing for this possibility.

• The additional presence of more chronic, less intense, and less sharp pain does not preclude a diagnosis of TN as long as the other type of pain is present, and this type of pain may in fact be due to the severe facial contractions that occur in reaction to TN episodes.

• TN patients can often have periods of remission, which in some cases can last for years. However, recurrence is common, and generally any subsequent remission periods are of increasingly shorter duration.

• There is also often a specific “trigger” zone, which can bring on a pain episode when stimulated. Stimuli which are frequently reported as provoking TN symptoms include chewing, brushing teeth, rubbing the area of ...

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