Atypical Facial Pain

presented by

David Elpern M.D., Williamstown, MA, USA

on September 30, 2004



1: Burchiel KJ. A new classification for facial pain. Neurosurgery. 2003 Nov;53(5):1164-6; discussion 1166-7.

Department of Neurological Surgery, Oregon Health and Science University,
Portland, Oregon 97239, USA.

PURPOSE: A patient-oriented classification scheme for facial pains commonly encountered in neurosurgical practice is proposed.

CONCEPT: This classification is driven principally by the patient's history.

RATIONALE: The scheme incorporates descriptions for so-called "atypical" trigeminal neuralgias and facial pains but minimizes the pejorative, accepting that the physiology of neuropathic pains could reasonably encompass a variety of pain sensations, both episodic and constant. Seven diagnostic labels result: trigeminal neuralgia Types 1 and 2 refer to patients with the spontaneous onset of facial pain and either predominant episodic or constant pain, respectively. Trigeminal neuropathic pain results from unintentional injury to the trigeminal nerve from trauma or surgery, whereas trigeminal deafferentation pain results from injury to the nerve by peripheral nerve ablation, gangliolysis, or rhizotomy in an intentional attempt to treat either trigeminal neuralgia or other facial pain.
Postherpetic neuralgia follows a cutaneous herpes zoster outbreak (shingles) in
the trigeminal distribution, and symptomatic trigeminal neuralgia results from
multiple sclerosis. The final category, atypical facial pain, is synonymous with
facial pain secondary to a somatoform pain disorder. Atypical facial pain can be suspected but not diagnosed by history and can be diagnosed only with detailed and objective psychological testing.

CONCLUSION: This diagnostic classification would allow more rigorous and objective natural history and outcome studies of facial pain in the future.

2. Graff-Radford SB. Facial pain. Curr Opin Neurol. 2000 Jun;13(3):291-6. .

The Pain Center, Los Angeles, CA 90048, USA.

Facial pain is a debilitating disorder if left untreated. Too often patients are
labelled as having psychopathology when face pain etiology is unclear. These
patients are categorized as 'atypical', 'idiopathic' or 'psychogenic'. Idiopathic, when referring to a medical problem suggests that there is something unknown, and does not define the problem. The same applies to terms incorporating the word 'atypical'. It is postulated that the most commonly undiagnosed facial pain conditions include neuropathic and myofascial pains because their pathophysiologies are not well understood. Peripheral and central mechanisms associated with these disorders are used to provide an update of these frequently seen clinical conditions.