Clinical presentation and symptoms
Patients describe their sensations as constant, dull, and aching pain. It is usually localized in the upper jaw, forehead, or cheek areas. The process may affect one or both sides of the face.
Pain syndrome rarely occurs in isolation. It is almost always accompanied by pronounced comorbid disorders:
- sleep and appetite disturbances;
- decreased sexual desire (libido);
- constant fatigue and increased irritability.
Worsening of symptoms or their initial onset is frequently triggered by external and internal factors: exposure to cold, physical overexertion, or severe stress. During history taking, many patients report a prior facial trauma, after which pain persisted in the injured area for a long time. Due to the chronic course, patients experience impaired social adaptation and occupational difficulties.
Diagnostic criteria and differential diagnosis
Since atypical facial pain is considered a somatoform pain disorder, confirming it requires meeting three strict criteria:
- Presence of intense pain that causes the patient distress (a sharply negative emotional reaction).
- Almost continuous course of the pain syndrome for 6 months or more.
- Complete absence of somatic diseases capable of causing the symptoms.
Differential diagnosis is carried out with the following conditions:
- Trigeminal neuralgia: unlike atypical facial pain, trigger zones are completely absent.
- Malingering: symptoms in atypical pain arise completely unintentionally, and the patient pursues no secondary gain.
- Dental diseases and temporomandibular joint (TMJ) dysfunction: the diagnosis of atypical pain is valid only after excluding these pathologies.
Management tactics and treatment principles
Treatment requires eliminating the factors maintaining the pain syndrome. For the muscular component of facial pain, non-pharmacological methods are used: acupuncture and post-isometric relaxation (e.g., stretching the masticatory muscles with fingers). For a rapid but temporary effect, trigger point injections with 0.5% procaine solution are performed. If jaw occlusion abnormalities are present, dental correction is mandatory.
Since psychogenic factors often underlie the disease, psychotherapy (including relaxation techniques) is indicated. A mandatory stage of patient management is a psychiatric consultation to diagnose affective disorders, schizophrenia, or hypochondriacal states. If emotional disturbances are confirmed, psychotropic pharmacotherapy—antidepressants and tranquilizers—is prescribed.
Burning mouth syndrome (glossodynia)
A closely related condition in terms of mechanism is burning mouth syndrome. It manifests as bilateral burning of the oral mucosa (predominantly at the tip of the tongue), taste alterations, dryness, and sensory disturbances (dysesthesia).
The disease is typical for postmenopausal women. The diagnosis is made clinically if symptoms last for more than 2 hours a day for 3 months.
The syndrome may be secondary, so before making a diagnosis, the following must be excluded:
- Local causes: candidiasis, oral lichen planus, salivary deficiency.
- Systemic diseases: folic acid or vitamin B12 deficiency, diabetes mellitus.
- Iatrogenic factors: side effects of medications.
If objective causes are absent and the mucous membrane is unchanged, the patient is also referred to a psychiatrist to rule out depressive and somatoform disorders.
Briefly: answers to topical questions
How does atypical facial pain clinically differ from trigeminal neuralgia?
Atypical facial pain clinically differs from trigeminal neuralgia in the character of the pain syndrome and the absence of trigger points.
| Sign | Atypical facial pain | Trigeminal neuralgia |
|---|---|---|
| Pain characteristics | Constant, aching, dull | Paroxysmal: shooting, stabbing like a dagger, sensation of electric shock |
| Trigger points | Absent | Present and can trigger an attack |
| Duration | Almost constantly, at least 6 months | Attacks lasting from a few seconds to 2 minutes |
What pathogenetic mechanisms underlie the development of atypical facial pain?
The pathogenesis of atypical facial pain is based on mental disorders in the absence of somatic disease.
- Concealed depression is the most frequent cause of the pain syndrome.
- Psychiatric pathologies — schizophrenia, affective disorders, as well as undifferentiated somatoform or hypochondriacal disorder may be detected.
The disease is considered a somatoform pain disorder, in which symptoms are unintentional and confer no secondary gain to the patient.
What instrumental studies are ordered to rule out somatic pathology in facial pain?
Neuroimaging methods are ordered to rule out somatic pathology and structural abnormalities in facial pain.
- Magnetic resonance imaging (MRI) is the leading method to rule out a symptomatic nature of pain (detection of brain tumors, multiple sclerosis).
- Computed tomography (CT) is used to examine the head and neck to rule out space-occupying lesions.
Distinguishing atypical pain from trigeminal neuralgia is easy: in atypical pain there are NO trigger points, the pain is dull (rather than shooting) in character, and it brings no secondary gain to the patient (unlike malingering).
Class and exam questions
Why is a psychiatric consultation mandatory in atypical facial pain?
This is due to the fact that psychiatric pathologies—such as masked depression, schizophrenia, or somatoform disorders—most frequently lie hidden behind this syndrome.
What factors can trigger an attack or intensify the pain?
Worsening of symptoms is frequently triggered by cold weather, stressful situations, and intense physical exertion.
How is muscular facial pain accompanying the syndrome treated?
Post-isometric relaxation, acupuncture, and trigger point injections with 0.5% procaine solution are used for temporary relief.
What else to study on this topic
- Methods for detecting concealed depression using specialized questionnaires
- Performing differential diagnosis with temporomandibular joint dysfunction
- Principles of using antidepressants and tranquilizers in chronic pain
- Technique of post-isometric relaxation of the masticatory muscles
- Impact of vitamin B12 deficiency and diabetes mellitus on the development of glossodynia
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Other topics in "Chapter 29. Facial Pain"
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