Causes of Facial Pain

The most frequent cause of facial pain is neuralgia of the trigeminal nerve (trigeminia). The prevalence of trigeminal neuralgia is quite high and amounts to 30-50 patients per 100 000 population, and the incidence according to WHO is in the range of 2-4 people per 100 000 population. More often neuralgia of the trigeminal nerve occurs in women 50-69 years old and has right-lateral lateralization. The development of the disease contributes to various vascular, endocrine, allergic disorders, as well as psychogenic factors. It is believed that trigeminal neuralgia is an idiopathic disease. However, there are several theories explaining the pathogenesis of the disease. The most likely cause of neuralgia of the trigeminal nerve is the compression of the trigeminal nerve at the intra- or extracranial level, and therefore distinguish neuralgia of central and peripheral genesis.

I. Vascular causes of facial pain:

1. Cluster (bundle) pain.
2. Chronic paroxysmal hemicrania (CPG).
3. Carotidinia.

II. Neurogenic causes of facial pain:

1. Neuralgia of the trigeminal nerve (and ganglion ganglion node).
2. Neuralgia of the glossopharyngeal nerve.
3. Neurtalgia of the overlying nerve.
4. Hant's neuralgia (ganglionitis of the cranial node of the intervening nerve).
5. Neck - Tongue Syndrome. Syndrome.
6. Occipital neuralgia.

III. Mixed (vascular-neurogenic) pain:

1. Paratrigeminal syndrome of Raeder ("pericarotid syndrome").
2. Temporal giant cell arteritis.

IV. Painful ophthalmoplegia of Tolosa-Hanta.

V. Pain syndromes of unknown origin:

1. SUNCT.
2. Idiopathic stabbing pain.
3. Reflex sympathetic facial dystrophy and "central" pain.

VI. Somatogenic pain:

1. Myogenic (myofascial pain syndrome).
2. Syndrome Kosten (dysfunction of the temporomandibular joint).
3. Arthrogenic.
4. Ophthalmic (glaucoma and other eye diseases).
5. Otorinogenic.
6. Odontogenic.
7. Visceral.

VII. Psychogenic causes of facial pain.

Vascular Causes of Facial Pain

Cluster (bundle) headaches are manifested by unilateral paroxysmal very severe pains of a burning, drilling or bursting character in the periorbital and temporal region, sometimes with wider irradiation. The duration of attack of the beam headache varies from 15 minutes to 3 hours. The pain is extremely intense, accompanied by anxiety, psychomotor activation, agitation. The frequency of attacks is from 1 to 8 times a day. Attacks are grouped into "bundles" of 2-6 weeks duration. The frequency of "beams", as well as the duration of remissions between them (usually several months or years) are individual. A characteristic sign of the headache is vegetative support in the form of hyperemia of the conjunctiva, lacrimation, nasal congestion, rhinorrhea, facial hyperhidrosis on the side of pain, eyelid edema and incomplete Horner syndrome on the same side.

Factors that provoke an attack of a bundle headache during a "beam" are most often alcohol, the intake of nitroglycerin or the administration of histamine. But often provoking factors can not be identified. Another important feature of the bundle headache is its frequent association with night sleep: from 50% to 75% of seizures occur during the "fast sleep" phase. Symptomatic forms of the "cluster" (pituitary tumor, anterior connective aneurysm, Tolosa-Hunt syndrome, etmoiditis) are described. In these cases, it is important to pay attention to atypical clinical features and concomitant symptoms.

Isolate episodic and chronic forms of cluster headache. With an episodic form (the most common variant), an exacerbation ("bundle") can last from 7 days to 1 year (usually 2-6 weeks) with a subsequent remission of at least 14 days. In chronic form, remission is either not observed at all, or it is much shorter - less than 14 days. Mostly men are aged 30-40 years.

Chronic paroxysmal hemicrania (CPG) resembles the headache of the head with its localization, intensity and vegetative accompaniment. Differences consist in the lack of puffiness and the presence of a stopping effect of indomethacin. In addition, chronic paroxysmal hemicrania, in contrast to beam pain, develops mainly in women in adulthood and old age.

Carotidinia is a seldom used term for collective significance, which is used to describe blunt pains caused by compression of the carotid artery or with weak faradic stimulation in the area of its bifurcation. Pain can cover the ipsilateral half of the face, the ear area, the lower jaw, teeth and neck. This syndrome is rarely seen in the picture of temporal arteritis, during a migraine attack or a headache; It is also described in the dissection of the carotid artery and the tumor of the cervical region displacing the carotid artery. A variant of (favorable) carotidinia is also described, in which the most thorough examination does not reveal any pathology.

Neurogenic causes of facial pain

Intracranial causes of compression may be a volumetric process in the posterior cranial fossa (tumors: neurinoma of the auditory nerve, meningioma, glioma of the bridge), dislocation and expansion of the crimped cerebellar arteries, veins, basilar artery aneurysm, meningitis, adhesions after trauma, infections. Among extracranial factors, there are: the formation of a tunnel syndrome (compression of the second and third branches in the bony canals - the infraorbital and mandible with their congenital narrowness and adherence of vascular diseases in old age), local odonto- or rhinogenic inflammatory process.

The role of compression of the trigeminal nerve became more understandable when a "portal theory of pain" appeared. Compression violates the axon, leads to activation of autoimmune processes and causes focal demyelination. Under the influence of prolonged pathological impulses from the periphery in the spinal cord of the trigeminal nerve, a "focus", similar to the epileptic one, is the generator of pathologically enhanced excitation (GPOO), whose existence no longer depends on afferent impulses. The pulses from the trigger points arrive at the driving neurons of the generator and cause it to be lightly activated. The GPOO activates reticular, mesencephalic formations, thalamus nuclei, cerebral cortex, involves the limbic system, thus forming a pathological algogenic system.

The disease can develop after removal of the tooth (the lunar nerve is affected) - odontogenic neuralgia; as a result of circulatory disorders in the brainstem, herpetic infection; rarely due to demyelination of the spine of the trigeminal nerve with multiple sclerosis. Provoking factors may serve as an infection (influenza, malaria, syphilis, etc.), hypothermia, intoxications (lead, alcohol, nicotine), metabolic disorders (diabetes).

Neuralgia of the trigeminal nerve

It is manifested by attacks of severe burning (shooting) facial pain in the zone of innervation of the trigeminal nerve. The attack lasts from a few seconds to 1-2 minutes (rarely more). The attack occurs suddenly in the maxillary or mandibular region and irradiates upwards, to the eye or to the ear. Touches, movements, food provoke and exacerbate pain, which can last for a long time, interrupted by the same long-term remissions. The clinic is so characteristic that usually no other studies are required. In very rare cases, facial pain can occur with multiple sclerosis or with stem tumors, so there is a need for a complete examination, especially in young patients. Without treatment, facial pain progresses, remissions become shorter and dull pain remains between remissions. Pain in trigeminal neuralgia has the following characteristics:

1. Paroxysmal character, duration of attack is no more than 2 minutes. There is always a "light" gap between the two seizures.
2. Significant intensity, suddenness, reminiscent of electric shock.
3. Localization is strictly limited to the zone of innervation of the trigeminal nerve, usually 2 or 3 branches (in 5% of cases, -1 branch).
4. The presence of trigger points (zones), a weak irritation of which causes a typical paroxysm (they may be in a painful or painless zone). Most often trigger zones are located in the orofacial area, on the alveolar process, with the first branch affected - at the medial angle of the eye.
5. Presence of trigger factors (most often it is washing, talking, eating, brushing teeth, air movement, simple touch).
6. Typical painful behavior. Patients, trying to wait for the attack, freeze in the position in which they found pain paroxysm. Sometimes grind the area of pain or make smacking movements. During the attack, patients respond to questions in monosyllables, barely parting their mouths. At the height of paroxysm can be twitching of the facial musculature (tic douloureux).
7. Neurological deficits in typical cases of neuralgia of the trigeminal nerve are absent.
8. The vegetative accompaniment of attacks is scant and is observed in less than 1/3 of patients.

In most patients, trigeminal neuralgia develops secondary myofascial prozopalgic syndrome over time. Its formation is explained by the fact that patients are forced to use the side of the mouth for chewing predominantly contralateral pain. Therefore, the muscles of the homolateral side develop degenerative changes with the formation of typical muscle nodules.

The disease flows with exacerbations and remissions. In the period of attacks, pain can be grouped by volleys. The volleys can last for hours, and the periods of attacks last for days and weeks. In severe cases, the daily activity of patients is significantly impaired. In some cases, the status neuralgicus arises, when there are no gaps between individual volleys. Possible spontaneous remissions, against which the disease usually progresses. Remissions last for months and years, but as relapses occur, patients begin to feel pain, which persists between attacks.

Neuralgia of other branches of the trigeminal nerve

Damage or compression of the branches of the trigeminal nerve can cause pain in the zone of their innervation.

• Neuralgia (neuropathy) of the infraorbital nerve is usually symptomatic and is caused by inflammatory processes in the maxillary sinus or nerve damage in complex dental manipulations. Pain is usually of minor intensity, a feeling of numbness in the mucosa of the upper jaw and the infraorbital region predominates.
• Causes of neuralgia of the lingual nerve may be prolonged irritation of the tongue with a prosthesis, a sharp edge of the tooth, etc. Moderate pain in half of the tongue is of a permanent nature and at times intensifies with eating, talking, and sharp facial movements.
• Neuralgia (neuropathy) of the lower alveolar nerve occurs with injuries and inflammatory diseases of the lower jaw, when the filling material leaves the top of the tooth, with the simultaneous removal of several teeth. It is characterized by a moderate permanent pain in the teeth of the lower jaw, in the region of the chin and lower lip. In some cases, neuropathy of the terminal branch of the lower alveolar nerve - the chin nerve - is observed. It manifests itself as hypostasis or paresthesia in the region of the chin and lower lip.
• Neuropathy of the buccal nerve is usually combined with neuropathy of the lower alveolar nerve. Pain syndrome is absent, typical hypoesthesia of the mucous membrane of the cheek, as well as the skin of the corresponding angle of the mouth.
• The term "tick-neuralgia" refers to the combination of periodic migraine neuralgia and neuralgia of the first branch of the trigeminal nerve.

Postherpetic neuralgia of the trigeminal nerve

Postherpetic neuralgia of the trigeminal nerve is a persistent or recurring facial pain for at least 3 months after the onset of Herpes zoster infection. Postherpetic neuralgia of the trigeminal nerve is observed much more often than classical trigeminal neuralgia (2 per 1000, and in individuals older than 75 years - Yuna 1000 population). The defeat of the trigeminal nerve is noted in 15% of herpes zoster, and in 80% of cases the eye nerve is involved in the process (which is related to its minimal myelination as compared to the II and III branches of the V pair of cranial nerves). The appearance of the disease predisposes a decrease in immunity in the elderly, contributing to the activation of a persistently persistent virus in the body of Varicella-zoster. The development of the disease passes through several stages: prodromal, previous rash (acute pain, itching); unilateral rash (vesicles, pustules, crusts); skin healing (2-4 weeks); postherpetic neuralgia. For a neurologist, the diagnosis of the prodromal phase is important, when there are no rashes yet, but the pain syndrome has already appeared. To suspect herpes zoster allows revealing pink spots on the skin, in the zone of which there are itching, burning, pain. After 3-5 days, the erythematous background disappears and bubbles appear on the healthy skin. After the appearance of the rash, the diagnosis is not difficult. In the case of the development of postherpetic neuralgia of the trigeminal nerve, after the crusts fall and the skin heals with the scarring elements, the leading complaint becomes permanent pain that occurs within 1 month in 15% of cases, and within a year - in 25%. Risk factors for postherpetic neuralgia include elderly age, female gender, the presence of severe pain in the prodromal stage and acute period, as well as the presence of severe skin rashes and subsequent scarring of the skin. Clinical manifestations in the advanced stage of postherpetic neuralgia are very typical.

• Scars on the skin (against the background of its hyper- and hypopigmentation) in the forehead and scalp.
• Presence of trigger areas on the scalp (symptom of the comb), forehead, eyelids.
• A combination of permanent and paroxysmal pain syndromes.
• The presence of allodynia, hypoesthesia, dysesthesia, hyperalgesia, hyperpathy.

Neuralgia of the naso-ciliary nerve (Charlene's syndrome)

It is accompanied by severe pain in the medial angle of the eye with irradiation in the back of the nose, sometimes orbital and near-orbital pain. The duration of the attack is from a few hours to a day. Pain syndrome is accompanied by lacrimation, photophobia, flushing of the sclera and nasal mucosa, edema, hyperesthesia on the affected side and one-sided hypersecretion of the nasal mucosa. Treatment: non-narcotic analgesics and NSAIDs; Bury in the eye and nose 0.25% solution of dicaine 1 -2 drops, to enhance the effect - 0.1% solution of adrenaline (3-5 drops per 10 ml of dicain).

Neuralgia of the auriculotemporal nerve (Frey syndrome)

It is characterized by the appearance on the side of defeat of paroxysmal pain in the depth of the ear, in the area of the anterior wall, external auditory canal and temple, especially in the temporomandibular joint area, often with irradiation into the lower jaw. It is accompanied by hyperemia of the skin, increased sweating in this area, salivation, a change in pupil size on the side of the lesion. Attacks are provoked by the reception of a certain food and even when it is presented, as well as by external stimuli. Treatment: analgesics in combination with antihistamines, tranquilizers, neuroleptics; NSAIDs, vegetotrophic (belloid, bellaspon).

Neuralgia of the lingual nerve

Diagnosis is based on clinical data: the presence of attacks of burning facial pains, anterior 2/3 of the half of the tongue, which appear spontaneously or are provoked by ingestion of rough, spicy food, movements of the tongue, infections (tonsillitis, tonsillitis, influenza), intoxications, etc. On the corresponding half of the tongue, there are often disorders of sensitivity, more often as hyperesthesia, with prolonged flow, loss of pain and taste sensitivity. Treatment: analgesics - analgin, cigans, on the tongue - 1% solution of lidocaine, anticonvulsants, vitamins of group B.

Neuralgia of the facial nerve

In the picture of facial nerve neuropathy, the pain syndrome is manifested by shooting or aching pain in the region of the external auditory canal, with irradiation into the homolateral half of the head, migration in the region of the eyebrow, cheeks, inner corner of the eye, nose and chin wing, which increases with emotional stress in the cold and is facilitated under the influence of heat. Facial pain is accompanied by facial asymmetry along with a peculiar defect in mimicry, pathological synkinesia and hyperkinesia, development of paresis and secondary contracture of facial muscles, occurs after hypothermia, less often against the background of acute respiratory viral infection. Complex treatment includes "drug decompression" of the nerve in the facial canal (prescription of prednisolone, diuretics), vasoactive therapy (euphyllin, nicotinic acid), vitamins of B group, physiotherapy treatment, curative gymnastics, massage.

Neuralgia of the superior laryngeal nerve (branch of the vagus nerve)

Characterized by a one-sided pain of paroxysmal nature in the larynx that radiates into the ear and along the lower jaw, occurs during eating or swallowing. Sometimes laryngospasm develops during a bout of pain, a cough appears, a general weakness.

Wing-palatal syndrome (Slader's syndrome)

Attacks of acute pain in the eye, nose, upper jaw. Pain can extend to the area of the temple, ear, neck, neck, shoulder blade, shoulder, forearm, hand. Paroxysms are accompanied by pronounced vegetative symptoms: redness of half of face, swelling of facial tissues, lacrimation, abundant secretion from one half of the nose (vegetative storm). The duration of the attack from several minutes to days.

Myofascial facial syndrome

The main clinical manifestation is the combination of neuralgia of one of the cranial nerves (pain in the face, tongue, mouth, pharynx, larynx), motor disorders from the chewing muscles, a violation of taste, dysfunction of the temporomandibular joint. Facial pains do not have clear boundaries, duration and intensity of their different (from the state of discomfort to severe painful pain). Increases pain emotional stress, compression of the jaws, overload of the chewing muscles, fatigue. The pain depends on the state of activity and localization of trigger points. There may be vegetative symptoms: sweating, vasospasm, runny nose, tear and salivation, dizziness, tinnitus, burning sensation in the tongue, etc.

Treatment of these syndromes is carried out together with a neurologist.

Supraorbital neuralgia

The disease is observed as rarely as nasociliary neuralgia. It is characterized by paroxysmal or permanent pain in the region of the supraorbital incision and the medial part of the forehead, that is, in the zone of innervation of the supraorbital nerve. When palpation is determined soreness in the area of supraorbital tenderloin.

Neuralgia of the glossopharyngeal nerve

The classical neuralgia of the glossopharyngeal nerve in clinical manifestations resembles neuralgia of the trigeminal nerve (which often becomes the cause of diagnostic errors), but it develops significantly less often than the latter (0.5 per 100 000 population).

The disease occurs in the form of painful paroxysms starting in the root of the tongue or tonsil and extending to the palatine curtain, pharynx, ear. Pain sometimes radiates into the corner of the lower jaw, eye, neck. Attacks, as a rule, are short-lived (1-3 min), are provoked by movements of the tongue, especially in loud conversations, with the intake of hot or cold food, irritation of the root of the tongue or amygdala (trigger zones). Pain is always one-sided. During the attack, patients complain of dryness in the throat, and after an attack hypersalivation appears. The amount of saliva on the side of pain is always reduced, even during the period of salivation (in comparison with the healthy side). Saliva on the side of pain is more viscous, its specific gravity is increased due to an increase in the mucus content.

In some cases, during an attack, the patients develop presyncopal or syncopal conditions (short-term faintness, dizziness, falling of arterial pressure, loss of consciousness). Probably, the development of these conditions is associated with irritation of the n. Depressor (branch of the IX pair of cranial nerves), as a result of which the depression of the vasomotor center and the drop in arterial pressure occur.

In an objective examination of patients with neuralgia of the glossopharyngeal nerve, no changes are usually detected. Only in a small part of cases is noted the painfulness at palpation of the angle of the mandible and some parts of the external auditory canal (mainly during an attack), a decrease in the pharyngeal reflex, a decrease in the mobility of the soft palate, a perversion of taste sensitivity in the posterior third of the tongue (all taste irritations are perceived as bitter) .

The disease, like the trigeminal neuralgia, proceeds with exacerbations and remissions. After several attacks, remissions of different duration are noted, sometimes up to 1 year. Nevertheless, as a rule, seizures gradually increase, and the intensity of the pain syndrome increases. In the future, there may appear permanent pains that increase under the influence of various factors (for example, when swallowing). Symptoms of prolapse corresponding to the innervation of the glossopharyngeal nerve (neuritic stage of the glossopharyngeal nerve neurasthenia) - hypesthesia in the posterior third of the tongue, the tonsil region, the palatine curtain and the upper part of the pharynx, the violation of taste on the root of the tongue, the reduction of salivation (due to the parotid salivary gland ).

The classical neuralgia of the glossopharyngeal nerve, like the trigeminal neuralgia, is most often due to the compression of the nerve by the branch of the vessel in the region of the medulla oblongata.

The symptomatic neuralgia of the glossopharyngeal nerve differs from the classical one by the frequent presence of constant aching pain in the interstitial period, as well as progressive impairment of sensitivity in the innervating zone of the glossopharyngeal nerve. The most frequent causes of symptomatic neuralgia of the glossopharyngeal nerve are intracranial tumors, vascular malformations, volumetric processes in the region of the styloid process.

Neuralgia of the tympanic plexus

Neuralgia of the tympanic plexus (Reichert's syndrome) manifests itself as a symptom complex similar to that of the knee joint (although the tympanic nerve is a branch of the glossopharyngeal). This is a rare form of facial pain, the etiology and pathogenesis of which are still unclear. There are suggestions about the role of infection and vascular factors.

Typical acute shooting pains in the area of the external auditory canal, appearing paroxysmally and gradually subsiding. Pain occurs without apparent external causes. At the onset of the disease, the frequency of seizures does not exceed 5-6 times a day. The disease occurs with exacerbations, which last for several months, and then are replaced by remissions (lasting also several months).

In some patients, the development of the disease can be preceded by unpleasant sensations in the area of the external auditory canal, which sometimes spread to the entire face. When examining objective signs are usually not detected, only in some cases, note the soreness in palpation of the auditory canal.

Neuralgia of the nerve

Neuralgia of the intervening nerve is a rare disorder characterized by short paroxysms of pain in the depth of the ear passage. The main diagnostic criteria are periodic paroxysms of pain in the depth of the ear passage lasting from several seconds to several minutes, mainly on the back wall of the ear passage, where there is a trigger zone. Sometimes pain can be accompanied by violations of tear, salivation and / or taste disorders, often a connection with Herpes zoster is found.

Neuralgia of the superior nerve of the larynx

Neuralgia of the upper nerve of the larynx is a fairly rare disorder, manifested by intense pain (paroxysms of pain lasting from several seconds to several minutes) in the region of the lateral wall of the pharynx, submandibular region and below the ear, provoked by swallowing movements, loud conversation or head turns. Trigger zone is located on the lateral wall of the pharynx above the membrane of the thyroid gland. With idiopathic form, pain is not associated with other causes.

Freya Syndrome

Frey's syndrome (neuropathy of the ear-temporal nerve, ear-temporal hyperhidrosis) is a rare disease, manifested by insignificant unstable pains in the parotid region, as well as hyperhidrosis and hyperemia of the skin in the parotid region when eating. Usually the cause of the disease is trauma or surgery in this area.

Musculoskeletal prozochrialygia

Skeletal-muscular prosocranialgia are most often associated with dysfunction of the temporomandibular joint and myofascial pain syndrome.

For the first time, the term "painful dysfunctional syndrome of the temporomandibular joint" was introduced by Schwartz (1955), describing its main manifestations - a violation of the coordination of masticatory muscles, a painful spasm of the chewing musculature, and restriction of the movements of the lower jaw. Subsequently, Laskin (1969) proposed another term - "myofascial painful dysfunctional face syndrome" with the identification of 4 main symptoms: pain in the face, soreness in the study of masticatory muscles, restriction of opening of the mouth, clicks when moving in the temporo-jaw joint. In the development of the syndrome, two periods are distinguished - the period of dysfunction and the period of painful spasm of the chewing musculature. At the same time, the beginning of this or that period depends on various factors affecting chewing muscles, of which psychoemotional disorders, leading to reflex spasm of the masticatory muscles, are considered the main ones. With muscle spasm, painful areas arise - trigger (trigger) zones, from which the pain irradiates into neighboring areas of the face and neck.

The characteristic diagnostic signs of myofascial pain syndrome are now considered to be the pain in the chewing muscles that increase with the movements of the lower jaw, the limitation of its mobility (opening the mouth to 15-25 mm between the incisors instead of 46-56 mm in norm), clicks and crepitation in the joint, S-shaped deflection of the lower jaw toward or forward when opening the mouth, pain during palpation of the muscles lifting the lower jaw. When palpation of the chewing musculature, painful seals are found (muscle trigger points). Stretching or squeezing these areas causes the appearance of pain that spreads to the neighboring areas of the face, head, neck (the so-called painful muscle pattern). The pain pattern corresponds not to neural innervation, but to a certain part of the sclerotome.

The development of myofascial pain dysfunctional syndrome is associated with prolonged stress of the masticatory muscles without their subsequent relaxation. First, a residual stress arises in the muscle, then in the intercellular space local seals are formed due to the transformation of the intercellular fluid into myogloidal nodules. These nodules also serve as a source of pathological impulses. The most common muscular trigger points are formed in the pterygoid muscles.

It was revealed that musculoskeletal prozopalgia often occurs in middle-aged people with asymmetric adentia, as well as with some behavioral habits (jaw clenching in stressful situations, support of the chin by the hand, extension of the lower jaw to the side or forward). X-ray changes in this case may be absent. In many cases, psychological causes (depression, hypochondria, neuroses) are of paramount importance in the formation of the disease.

Cervical-prosocarcinialgia

Cervical-lingual syndrome is manifested by pains in the occipital or upper cervical region that arise when the head turns sharply and accompanied by unpleasant sensations in the middle of the tongue (dysesthesia, numbness and pain).

Pain in the language is reflected and is caused by the pathology of the cervical spine, most often a subluxation of the atlanto-occipital articulation. The development of this syndrome is due to the fact that proprioceptive fibers from the tongue enter the spinal cord in the second dorsal cervical root and have connections with the lingual and sublingual nerves. This fact explains the appearance of unpleasant sensations in the language with compression of C ₂ (which is often observed with the subluxation of the atlantoaxial junction).

The syndrome of the styloid process is manifested by pains of mild or moderate intensity in the posterior part of the oral cavity that arise when swallowing, lowering the lower jaw, turning the head to the side, and palpation of the projection of the region of the shilo-lingual ligament. The syndrome is caused by the calcification of the shilo-lingual ligament, but it can also develop with a neck or lower jaw injury. To protect themselves from the appearance of seizures, patients try to keep their head straight, with a slightly raised chin (hence one of the names of the disease - "eagle syndrome").

[1], [2]

Central facial pain

The central facial pains include painful anesthesia (anaesthesia dolorosa) and central pain after a stroke.

• Painful anesthesia of the face is manifested by burning, permanent pains, hyperpathy in the zone of innervation of the trigeminal nerve, which usually arise after the nervesector of the peripheral branches of the V pair of cranial nerves or the thermocoagulation of the semilunar node.
• Central facial pain after a stroke is most often combined with hemidizesthesia on the opposite side of the body.

[3], [4]

Glossalgia

The incidence of the disease in the population is 0.7-2.6%, and in 85% of cases it develops in women in menopause. Often combined with the pathology of the gastrointestinal tract. Unpleasant sensations can be limited only to the front 2/3 of the tongue or spread to the front sections of the hard palate, the mucosa of the lower lip. Characteristic are the symptoms of the "mirror." (Daily examination of the tongue in the mirror to detect any changes), the "food dominant" (pain decreases or stops during eating), impaired salivation (usually xerostomia), taste changes (bitterness or metallic taste), psychological problems (irritability, fear, depression). The disease is characterized by a prolonged course.

Occipital neuralgia

This term is currently used rarely to denote paroxysms of pain in the zone of the large and small occipital nerves. The defeat of the occipital nerves in this zone is considered doubtful. With whiplash injuries of the neck or degenerative processes in the region of the intervertebral joints C2-S3 with compression of the third occipital nerve (branch of the posterior root of the NW), a pain syndrome with unilateral occipital and occipital neck pain and sensitivity disorder in this zone can develop.

A myofascial pain syndrome in the area of the suboccipital muscles is described, in which pain can be felt in the area of the eye and forehead (face area). Isolated (without simultaneous involvement of other posterior cervical muscles), this syndrome is rare.

Mixed (vascular-neurogenic) facial pain 

Paradigeminal Raerder syndrome is described in the previous section and manifests itself as a half-headache of the vascular type, facial pains of a neuralgic nature in the innervation of I and II branches of the trigeminal nerve and Horner's syndrome (but with persistent sweating on the face) on the same side. Possible involvement of chewing muscles (motor portion of the third branch of the V nerve). For the diagnosis, evidence of involvement of the trigeminal nerve is needed. Differential diagnosis is carried out with a bundle headache and other vascular headaches.

The temporal (giant cell) arteritis is manifested by fever, headache, pain in the muscles, an increase in ESR up to 40 - 70 mm / h, anemia. Mostly women are over 50 years old. Part of the patients develop ischemic disorders of cerebral circulation and ischemic neuropathies of the cranial nerves (more often unilateral or bilateral lesions of the visual, oculomotor and distracting nerves). Headache can be one-sided and two-stringed.

Differential diagnosis is carried out with brain tumors, trigeminal neuralgia, glaucoma, senile amyloidosis, nonspecific aortoarteriitis. In unclear cases, biopsy of the temporal artery is indicated.

Hunt's syndrome

In the herpetic infection, in addition to the trigeminal nerve, III, IV, and / or VI pairs of cranial nerves may also be affected, and in infectious lesions of the geniculate ganglion, the function of the facial and / or pre-collar nerve can be disrupted.

• Hunt-1 syndrome (the neuralgia of the knee joint, the syndrome of the knee joint, Herpes zoster oticus, Zoster oticus), described by the American neurologist J. Hunt in 1907, is one of the forms of herpes zoster that proceeds with the involvement of the knee joint. In an acute period, the rashes are localized in the external auditory canal, on the auricle, soft palate, palatine tonsils. The clinical picture of postherpetic neuralgia of the knee joint consists of one-sided permanent or periodic pain in the ear area, in the ipsilateral half of the face, external auditory canal, impaired taste in the anterior 2/3 of the tongue, moderate peripheral paresis of the facial muscles.
• Hunt-2 syndrome is caused by the defeat of sensory nodes of several cranial nerves - pre-vertebral, coxaeopharyngeal, vagus, and second and third cervical spinal nerves. Herpetic eruptions appear in the external auditory canal, the front 2/3 of the tongue, on the scalp. Pain in the back of the oral cavity radiates into the ear, back of the neck, and is accompanied by a salivation disorder, horizontal nystagmus, dizziness.

Tholos-Hunt Syndrome

The Tholos-Hunt syndrome arises suddenly and is characterized by periodic pain in the orbit, its edema, and also the defeat of one or several cranial nerves (III, IV and / or VI), usually passing independently. In some cases, the disease occurs with an alternation of remissions and exacerbations. In some patients, there is a violation of sympathetic innervation of the pupil.

The defeat of the cranial nerves coincides with the appearance of pain or occurs within 2 weeks after it. The cause of the Tolosa-Hunt syndrome is the proliferation of granulomatous tissue in the cavernous sinus, the upper orbital fissure or the orbit cavity. Painful ophthalmoplegia is also possible with neoplastic lesions in the area of the upper orbital gap.

Pain syndromes of unknown origin

The syndrome is a rare form of headache, whose nosological independence has not been conclusively proven. The pain syndrome is manifested by burning, stitching pain or a sensation of electric shock with a duration of 5 to 250 seconds. The frequency of attacks varies 1-2 per day to 10-30 per hour, sometimes acquiring the rhythm of "beams" with the localization of pain in the orbital and periorbital region. Attacks of pain are provoked by motions of the head and are sometimes caused by irritation of the skinning zones in the face. Some authors consider the ST syndrome a modified form of trigeminal neuralgia. The syndrome responds to carbamazepine. A symptomatic variant of STD syndrome (vascular malformation, angioma of the brain stem, craniostenosis, etc.) is described.

Reflex sympathetic facial dystrophy and "central" pain

Reflex sympathetic dystrophy (current term - complex regional pain syndrome - CRPS) is usually observed in one or another limb and is manifested by burning pain, hyperpathy and allodynia (sensory stimuli of different modalities in the pain zone are perceived as painful), as well as vasomotor, shipmotor and trophic violations. CRPS in the face area can develop after surgical and other penetrating trauma in the maxillofacial area, dental interventions. Most patients report burning, sometimes stabbing pains, which are amplified with a light touch, exposure to heat, cold and under the influence of emotional stress. Sometimes there is a local edema, redness, induration. But in the face area there is no osteoporosis, vascular and trophic disorders, typical for this syndrome in the limb region. Pain is stopped by sympathetic blockade or sympathectomy (star node).

Central (usually post-stroke) pain

It develops both in patients with a thalamus lesion and in the presence of an inconclusive localization of a stroke, but with the obligatory affection of the afferent structures of the brain. Between the stroke and the onset of pain, there is a latent period from several days to several months. Pain is characterized by a burning sensation resembling unpleasant sensations in the hand when immersed in ice water; often pain is described as lomizing, aching or constricting. Characteristic of allodynia (especially tactile). The pain usually develops against the background of regression of the original motor defect. Depending on the localization of the stroke, the pain in the face may be accompanied by an alternating pain syndrome (for example, with a lateral medullar infarction) in opposite extremities or localized throughout the contralateral half of the body and face. As a rule, this syndrome is accompanied by depression.

[5], [6], [7], [8]

Somatogenic facial pain

Myogenic (myofascial pain syndrome). Myofascial pain syndrome in the muscles of the neck and shoulder girdle can be manifested by reflected pain in a particular area of the face and head:

• Pain in the temporal region is characteristic of myofascial syndromes with trigger points in the trapezoidal, nodulating and temporal muscles.
• Pain in the frontal region - with myofascial syndrome in the nodal and semi-oedemic muscles of the head.
• Pain in the ear and temporomandibular joint - lateral and medial pterygoid muscle, as well as chewing and nicking muscles.
• Pain in the eye and eyebrows - nodding, temporal, belt and chewing muscles.

The Kosten syndrome is a dysfunction of the temporomandibular joint that develops with an incorrect bite and the uneven tension of the pterygoid, chewing and temporal muscles associated with it. Kosten's syndrome is manifested by unilateral aching pains in the parotid region, especially in front of the ear, which are aggravated by chewing. Opening the mouth is limited, which is not always realized by the patient. When opening the mouth, the jaw sometimes makes an S-shaped movement. In the masticatory muscle, trigger points are identified with characteristic reflected pain. Radiography does not detect changes in the temporomandibular joint.

Arthrogenic pains develop with arthrosis or arthritis of the temporomandibular joint, which lead to a similar clinical picture, but in contrast to Costen's syndrome they are accompanied by radiographic changes in the joint (narrowing of the joint gap, deformation of the articular surfaces and the head of the lower jaw, etc.).

Ophthalmic pain develops with glaucoma and other eye diseases (inflammatory, traumatic and volumetric processes, refractive disorders, phantom pain after enucleation of the eyeball); The latter are sometimes detected only with a special study. The pains are localized in the eyeball and periorbital, but may also have a wider spreading zone.

Otorhinogenic pain is typical for inflammatory diseases of the ear (otitis), sinuses (sinusitis, frontal, etmoiditis, sphenoiditis) and nearby structures (mastoiditis, petrositis). In these cases, headache and facial pain develop simultaneously with clinical and radiologic signs of the disease of the ENT organs and adjacent tissues.

Odontogenic facial pain can be observed in such processes as caries, pulpitis, periodontitis, abscess, gingivitis, diseases and damage to the oral mucosa (mechanical, chemical or thermal trauma, viral infections, iron deficiency anemia, radiation therapy in this area, osteomas and other tumors , diseases of salivary glands, damage to unknown etiology). Examination (examination, percussion, palpation) usually reveal the source of odontogenic pain. Depending on the cause and its localization in the oral cavity, pain can be irradiated beyond the mouth: the ear, the temporal region, the upper jaw, the lower jaw, the larynx, nose, forehead, crown.

Viscero-facial pains. Paresthesia with a painful component is described in polycythemia, during pregnancy, diseases of the digestive system. Cardiogenic pain in the area of the lower jaw is well known.

Intermediate ("psychosomatic") group consists of patients with glossalgia (glossalgia, glossodinia, oral dysesthesia, stomatalgia), which occur in about 1.5-2.5% of the population, and especially among women over 40 (up to 15%). These painful sensations are not accompanied by clinical symptoms of the defeat of the oral cavity and, what is characteristic, decrease and disappear during eating. 95% of these patients note certain diseases of the gastrointestinal tract. Typical emotional-affective disorders with the presence of anxiety-hypochondriacal manifestations. The importance of hormonal imbalance (menopause), malnutrition and psychogenic factors is discussed.

Psychogenic facial pain

Psychogenic facial pains in the practice of a neurologist are observed quite often, usually within the framework of a depressive syndrome or neuroses (hysteria).

• Hallucinogenic pain accompanies mental illnesses, such as schizophrenia, manic-depressive psychosis. They differ in the complexity and inaccessibility of understanding verbal characteristics and clearly pronounced sensopathic component ("snakes devour the brain", "worms move along the jaw", etc.).
• Hysterical facial pains are usually symmetrical, often combined with headaches, their intensity varies throughout the day. Patients describe them as "terrible, intolerable", but they have little effect on daily activity.
• Facial pains with depressions are more often bilateral, usually combined with headaches, often mark sensiopathies, expressed by simple verbal characteristics. Combine with the main symptoms of depression (motor retardation, bradyphrenia, mimic markers of depression, such as the lowered corners of the mouth, the crease of Werhaut, etc.).

Atypical facial pain

Pain that does not fit into the description of neurogenic, vegetative, musculoskeletal skeletal muscle is attributed to atypical facial pains. As a rule, their atypicity is associated with the simultaneous presence of signs characteristic of several types of pain syndromes, but the psychopathological component is usually dominant.

One of the variants of atypical facial pain is a persistent idiopathic facial pain. Pain can be triggered by surgical intervention on the face, facial trauma, teeth or gums, but its permanence can not be explained by any local cause. The pain does not correspond to the diagnostic criteria of any of the described forms of cranial neuralgia and is not associated with any other pathology. Initially, pain occurs in a limited area on one side of the face, for example, in the area of the nasolabial fold or one side of the chin. In some cases, patients generally can not precisely localize their feelings. In the area of pain, no disorders of sensitivity or other organic disturbances are detected. Additional methods of investigation do not reveal any clinically significant pathology.

Another form of atypical facial pain is atypical odontalgia. This term is used to refer to prolonged pain in the teeth or bed after tooth extraction in the absence of any objective pathology. This syndrome is close to the so-called "dental plexalgia". Among the patients, menopausal women predominate (9: 1). Typical constant burning pains in the area of teeth and gums, often with repercussion on the opposite side. Objective signs of dental or neurological disorders are usually absent, although in some patients the syndrome develops after dental manipulations (simultaneous removal of several teeth or the emergence of the filling material behind the apex of the tooth). In some cases, there is a decrease in pain during food intake and enhancement - under the influence of emotions, unfavorable meteorological factors and hypothermia.

With the defeat of the upper dental plexus, the pain can irradiate along the course of the second branch of the trigeminal nerve and be accompanied by vegetative symptoms, which are probably due to the connections of the plexus to the autonomic ganglia (the winged node and the upper cervical sympathetic node). As a rule, there are no painful tendencies at the exit points of the branches of the trigeminal nerve and marked sensitivity disorders in the zones of innervation of its II and III branches.

Two-sided dental plexalgia develops almost exclusively in women after the age of 40, is characterized by a prolonged course. Burning pains usually appear on one side, but soon appear on the opposite side. Almost all patients have pain on both sides within 1 year. It is possible and simultaneous development of bilateral pain. As with unilateral dental plexalgia, the upper dental plexus is affected 2 times more often than the lower one.

To the possible etiological factors of bilateral dental plexalgia include complex removals of wisdom teeth, premolars and molars, conductive anesthesia, osteomyelitis of the holes, surgical interventions on the jaws, ingress of the filling material into the mandibular canal through the root canals of the teeth, removal of a large number of teeth for a short time during preparation of the oral cavity for prosthetics, infection, intoxication, trauma, etc.

[9], [10], [11], [12]