There remains, after all the aforementioned facial pain syndromes, a fair number of patients with pain in the face for which no cause can be found. These patients are most often young women, who describe the pain as constant and unbearably severe, deep in the face, or at the angle of cheek and nose, and unresponsive to all varieties of analgesic medication. Because of the failure to identify an organic basis for the pain, one is tempted to attribute it to psychologic or emotional factors. Depression of varying severity is found in some. Some such patients, with or without depression, respond to tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI) medications. Differentiated from this group is the condition of trigeminal neuropathy with facial numbness, described in Chap. 44.
Facial pain of the “atypical type,” like other chronic pain of indeterminate cause, requires close observation of the patient, looking for lesions such as nasopharyngeal carcinoma or apical lung carcinoma to become apparent. The pain can be managed by the conservative methods outlined in the preceding chapter and not by destructive surgery. Antidepressants may be helpful, especially if the patient displays obsessive characteristics in relation to the pain; some European neurologists favor clomipramine for various facial and scalp pains.
Other Rare Types of Facial Pain
Neuralgia may arise in the terminal branches of the trigeminal, ciliary, nasociliary, and supraorbital nerves; some of which have already been mentioned. Some of these are vague entities at best and merely descriptive terms given to pains localized around the eye and nose. The Tolosa-Hunt syndrome of pain behind the eye and granulomatous involvement of some combination of cranial nerves III, IV, VI, and ophthalmic V, responsive to steroids, is discussed in Chap. 44.
A kind of reflex sympathetic dystrophy of the face is postulated as another rare form of persistent facial pain that may follow dental surgery or penetrating injuries to the face. It is characterized by severe burning pain and hyperpathia in response to all types of stimuli. Sudomotor, vasomotor, and trophic changes are lacking, unlike causalgia that affects the limbs. Nevertheless, this form of facial pain is said to respond to repeated blockade or resection of the stellate ganglion.
Under the title of neck–tongue syndrome, Lance and Anthony have described the occurrence of a sharp pain and tingling in the upper neck or occiput with numbness of the ipsilateral half of the tongue on sudden rotation of the neck. They attribute the syndrome to stretching of the C2 ventral ramus, which contains proprioceptive fibers from the tongue; these fibers run from the lingual nerve to the hypoglossal nerve and thence to the second cervical root.
A problem that has gone by the self-evident name burning mouth syndrome (stomatodynia) occurs mainly in middle-aged and older women, as commented in
Chap. 11. The tongue or other oral sites may be most affected or the entire oral mucosa may burn. A few patients are found to have diabetes, vitamin B12 deficiency, or Sjögren syndrome as possible causes. A hint to the last diagnosis is the inability to feel food in the mouth. The oral mucosa is normal when inspected, and no one treatment has been consistently effective, but gabapentin combined with antidepressants or clonazepam may be tried (see the review by Grushka et al). One of our patients with a limited form of this condition, which affected only the upper palate and gums, benefited from dental nerve blocks with lidocaine.
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