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4 Articles in this Series
Introduction
Complex Regional Pain Syndrome (CRPS): A Screening & Treatment Update
Facial Pain: Recognizing & Treating Trigeminal Neuralgia, Temporomandibular Disorders
Multiple Mini Interviews: The New Approach to Pain Fellow Recruitment
Neuropathic Pain: An Update on Practical Management Including Neurostimulation and Mechanism-Based Pharmacotherapy

Facial Pain: Recognizing & Treating Trigeminal Neuralgia, Temporomandibular Disorders

An Academy of Pain Medicine 2021 meeting highlight with Alexander Feoktistov, MD, and Sean Mackey, MD

Facial pain can be a debilitating condition for patients but with proper evaluation and appropriate treatment, clinicians can often either eliminate or greatly decrease that pain. In a virtual AAPM 2021 annual meeting session, experts addressed two challenging chronic facial pain conditions: trigeminal neuralgia and temporomandibular disorders (TMDs). Highlights are below.

Trigeminal Neuralgia

Prevalence and Pain Characteristics

While trigeminal neuralgia is not a common source of pain, ''It's certainly one of the more disabling,” said Alexander Feoktistov, MD, founder and director of the Synergy Integrative Headache Center in Chicago. About 0.3% of the population experiences trigeminal neuralgia, and women are more likely to be affected than men as are those over 50 years old – “but that data is constantly changing,” he clarifed.

The pain described from trigeminal neuralgia is typically very brief, lasting from only a couple of seconds to up to 2 minutes. Patients describe it as an electric shock that can be triggered by stimuli that seem innocuous, such as a brush to the cheek. “It can be triggered by light touch, shaving, chewing, swallowing hot or cold liquids,” explained Dr. Feoktisov. Even a blow of hot or cold air touching the face can set off the pain.

Trigeminal neuralgia almost always presents unilaterally. “If there is a bilateral presentation, I would always look for another cause,'' said Dr. Feoktisov, such as multiple sclerosis (MS), space-occupying lesions, or infections. The right side of the face is more often affected than the left. And in between attacks, patients may also report continuous, dull, ''background” pain.

Pain distribution is most commonly at the v2 (maxillary) and v3 (mandibular) nerve divisions. The location of the pain, he said, “is not always concordant with that particular trigger,” however. There is a refractory period – right after the acute attack – and “you can touch the same trigger zone and you would not be able to reproduce the attack again” due to changes in the nerve fiber.

Differential Diagnoses between Trigeminal Neuralgia and Other Head Pains

In most cases of classic trigeminal neuralgia (about 50% of those affected), Dr. Feoktistov described the physical exam as ''unremarkable.” For secondary sources, often caused by MS, there might be sensory loss on the affected side; the pain could be bilateral. The latter patients are usually younger, in their 20s and 30s. In some cases, an MRI is needed to pin down a diagnosis. The MRI could rule out the presence of brain tumor, MS, and other causes, for instance.

Trigeminal neuralgia is usually caused by pressure on the nerve exerted by a blood vessel near the brain stem. To differentiate the pain from other types, including headache pain, consider the duration of symptoms. As noted, in classic trigeminal neuralgia presentations, the pain typically lasts 2 to 120 seconds, much briefer than say, a cluster headache. Pain from a SUNCT (short-lasting, unilateral, neuralgiform headache) can also last 10 to 120 seconds but there is usually a strong presence of autonomic symptoms in those patients, said Dr. Feoktistov.

Trigeminal Neuralgia Treatment Options

Medication for trigeminal neuralgia is first-line, said Dr. Feoktistov, usually with anticonvulsants: carbamazepine (Tegretol), 200 to 1200 mg a day, or oxcarbazepine (Ostellar, Trileptal), 300 to 1800 mg a day. Other medications may be added on, if needed. Patients need to be warned of drowsiness and dizziness as side effects.

Some studies have found that botulinum toxin A (Botox) is an effective treatment but its off-label use is still investigational.

Surgical options include microvascular decompression, with separation of the blood vessel and nerve causing the pain. In good hands, surgery has resulted in long-term pain relief, noted Dr. Feoktistov. Other options include radiation to the nerve, balloon compression, with nerve blocks as a potential ''bridge therapy” while patients and doctors decide on another approach.

“Most important is to arrive at the correct diagnosis and then initiate condition-specific treatment,” Dr. Feoktistov told PPM. He advised against simply picking a painkiller when a patient presents with TN.

Temporomandibular Disorders

The NAM Consensus Report

Continuing the orofacial pain session at AAPM, Sean Mackey, MD, Redlich Professor and Chief, Division of Pain Medicine, Stanford University, focused on temporomandibular disorders (TMDs) including temporomandibular joint dysfunction (TMJ). He presented findings from the National Academy of Medicine Consensus Study Report on Temporomandibular Disorders, emphasizing priorities for research and care, which came out in 2020. Dr. Mackey served as vice-chair of the committee on TMDs, which was charged with evaluating the evidence and making recommendations.

The committee did not simply review the research, however, they obtained input from patients with TMDs and their family members, gathering data from more than 110 subjects. Their complaints? A lack of adequate care, trouble finding providers, impact on quality of life, among other issues. The patient input was sobering, such as one Dr. Mackey shared: “The pain from simply smiling can reduce me to tears.” Another pleaded for more research, saying: “There is no reason we should not have the research on the TM joint that exists on every other joint in the body.”

TMD diagnoses can be challenging to manage because they often coexist with other health issues, explained Dr. Mackey. TMDs often involve more than 30 disorders linked with pain or malfunction in the jaw joint and the jaw muscles. At the same time, much is still unknown about them. “We have yet to uncrate the causes and pathophysiology,'' he said, sharing that TMDs have been compartmentalized as simply a ''dental issue” for too long with many recommended procedures being too aggressive or costly. There are biological, psychological and social aspects of TMD disorders that need to be addressed.

Occlusal adjustment for TMDs, for instance, has been researched but the treatments have not been found to be effective, he said. The recommendations put forth by the committee are primarily tied to research so that new treatments and better patient outcomes can be achieved in the future:

  • Start a national collaborative research forum for TMD
  • Coordinate and expand TMD research
  • Improve access and quality of TMD healthcare
  • Develop and publicize evidence-based clinical practice guidelines and quality metrics for TMD care
  • Improve reimbursement and access to high-quality assessment, treatment and management of TMDs
  • Develop centers of excellence for TMDs and orofacial pain
  • Improve education and training on TMDs for healthcare professionals
  • Establish and strengthen advanced and specialized training in TMD care and orofacial pain
  • Raise awareness of TMDs, improve education among patients and reduce stigma

Overall, Dr. Mackey told PPM after the conference, “The number one thing anyone can do it to get educated. One of the biggest challenges we find it a lack of health education.”

 

Sources

Rubis, A. Juodzbalys G. The Use of Botulinum Toxin A in the Management of Trigeminal Neuralgia: A Systematic Literature Review. Journal of Oral Maxillofacial Research. 2020 June 30; 11(2)e2. Available at: https://pubmed.ncbi.nlm.nih.gov/32760475/

National Academy of Medicine: Temporomandibular Disorders: Priorities for Research and Care (2020). A Consensus Study Report.

Next summary: Multiple Mini Interviews: The New Approach to Pain Fellow Recruitment
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