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The diagnosis and management of patients with facial pain can be daunting even to experienced physicians. The causes are myriad, ranging from the mundane (sinus and dental disease) to the exotic (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing, or SUNCT). Misdiagnosis and mismanagement are common. The goal of this chapter is to discuss some of the more important causes of facial pain, and to guide proper identification and treatment.

Simply because pain is felt in the face does not imply that it necessarily originates in facial structures. As elsewhere in the body, pain may be local in origin, or referred. The role of the trigeminovascular system and the spinal trigeminal nucleus as a point of anatomic and physiologic convergence is discussed in Chapter 19. Suffice it to say that the location of the pain may not be so important diagnostically as other features.

The approach to the evaluation of facial pain requires careful attention to detail. In the history, it is essential to obtain an accurate description of the nature of the pain, or pains, what may have incited it, and what currently provokes and ameliorates it. Are there associated phenomena, such as autonomic changes? Past medical history, including trauma and surgical or dental procedures may provide essential clues. Is there associated depression or any other psychiatric problem? What therapies have been tried, and with what outcomes?

After obtaining a detailed history, a thorough examination is necessary. In addition to the general physical examination, a thorough neurologic examination is essential. The examiner looks for signs of raised intracranial pressure (papilledema, diminished up gaze, sixth cranial nerve palsies) and cranial nerve dysfunction (particularly oculosympathetic paresis). The head and neck require careful attention. Are there trigger points? Is there dental or sinus pathology? Auscultation for bruits and palpation of the carotid artery are sometimes informative maneuvers.

Lastly, the results of prior diagnostic studies are reviewed, noting the timing of the studies. Were the appropriate studies performed? If the situation has changed, perhaps a study should be repeated. Sometimes a diagnosis may become apparent only after serial clinical examinations or diagnostic studies, or both.

After a careful history, examination, and review of the data, a tentative diagnosis may be rendered. Often further consultation is required. Treatment is offered based on the tentative diagnosis and may, in itself, sometimes be diagnostic. The thoughtful physician should always be willing to reconsider the diagnosis.

Facial pain clearly represents a diagnostic challenge. With attention to the fundamental approach outlined in the preceding paragraphs, the vast majority of patients may achieve a satisfying outcome.

Neuralgias are paroxysmal pain in the distribution of a particular nerve. The pain is typically maximal at onset and lancinating, and may be described as “electric shocks” or “jabbing.” There may be a single sharp pain, or repetitive pains in succession. The pain may be so brief ...

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