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Headache and Orofacial pain - Assessment (3.7.1 - 3.7.16)

Updated: Mar 7, 2022

3.7.1 Appraise the International Classification of Headache Disorders


  • The ICHD-3 is the third edition of the taxonomy of headache disorders.

  • It is almost entirely evidence-based - earlier editions were more expert opinion

  • Electronic and multi-language versions are available

  • Classification is hierarchical - with overarching diagnoses becoming increasingly subcategorised as you descend the levels

  • Group --> Type --> Subtype --> Subform

  • If more than one diagnosis - it should be listed in order of importance to the patient

  • Classification is important for research trials and physiological studies

Pros of ICHD-3

Easy to use

Flexible coding


Clearly presented and can be followed

Empirically derived

Good validity


Orofacial pain disorders not described

No consideration for psychosocial and behavioural factors

30% were not classifiable of headaches at a tertiary facility


Split into:

Chronic primary headache (Headache occurring at least every 15 days within 30 over a 3 month period)

  1. Chronic migraine (unilateral throbbing and photo/phonophobia)

  2. Chronic tension-type headache (bilateral pressing and tight)

  3. Trigeminal autonomic cephalgias (autonomic features)

  4. Temporomandibular disorder (Muscle pain mastication and orofacial pain)

  5. Chronic burning mouth pain (Intraoral burning and dysaesthesia sensation)

  6. Chronic primary orofacial pain (pain in mouth face with emotional distress)

Chronic secondary headache

  1. Injury to head/neck

  2. Cranial or cervical vascular

  3. Intracranial

  4. Withdrawal or substance

  5. Infection

  6. Dental pain

  7. Neuropathic orofacial pain

  8. TMD pain


3.7.2 Generally discuss accepted definitions of terms associated with headache syndromes

Chronic daily headache - Headache on at least 15 days per month for at least 3 months

These were defined as headaches that last more than4 hours. This was to distinguish true chronic headaches from more paroxysmal episodic conditions such as the TACs


3.7.3 Describe a taxonomy of orofacial pain

Facial pain has been separated from headaches in the latest ICD-11 - these are more commonly from musculoskeletal sources and transmitted through the second and third branches of the trigeminal nerve

Headache is pain above the orbitomeatal and/or nuchal ridge. Facial pain is below this line

Otherwise, these conditions are defined and classified as per headache disorders

ICHD-3 -

There are several axes of classification.

a) Syndromology: neuralgia or neuropathy

The division between, for example, trigeminal neuralgia and trigeminal neuropathy should be viewed as a pragmatic way of distinguishing conditions in which clinical presentations and treatment approaches differ while the two conditions cannot be classified on the basis of currently known pathology or pathophysiology. The same applies to painful conditions associated with the glossopharyngeal and intermedius nerves.

An important cause of cranial-nerve pain is herpes zoster. Despite the fact that trigeminal pain following herpes zoster probably leads to different types of pathological change in trigeminal pathways (ie, “irritable nociceptor” versus “deafferentation” type), available data are too limited to classify them as neuralgia versus neuropathy. Therefore the well-established term post-herpetic neuralgia is maintained.

b) Location: central or peripheral neuropathic pain

A lesion or undue activation of these nerves (peripheral neuropathic pain), or of their central pathways (central neuropathic pain), causes neuropathic pain in the face.

c) Aetiology: classical, idiopathic or secondary

The cause of a neuropathic pain may be clear, such as infection by Varicella zoster virus or a structural abnormality (eg, multiple sclerosis plaque) demonstrated by imaging: such pain is termed secondary, and attributed to the cause. In other cases no cause is apparent (termed idiopathic).

For the trigeminal, glossopharyngeal and intermedius neuralgias, the term classical is reserved for cases where imaging or surgery has revealed vascular compression of the respective nerve. Strictly speaking, classical neuralgias are secondary (to the neurovascular compression), but it is beneficial to separate them from other causes on the basis of the wider therapeutic options and potentially different nerve pathophysiology.


3.7.4 Describe the anatomy of the cranial and upper cervical nerves and the innervation of the scalp, sinuses and teeth

Anterior distribution of cervical nerves

Cervical plexus (C1 - C4)

Brachial plexu (C5 - T1)

Posterior distribution of cervical nerve

  • Suboccipital nerve (C1)

  • Greater occipital nerve (C2)

  • Third occipital nerve (C3)

The major sensory dermatomes of the head and


Major scalp innervation

- Supratrochlear (CNV1)

- Supraorbital (CNV1)

- Lessor occipital

- Greater occipital

- Third occipital

- Zygoma9cotemporal (CNV2)

- Auriculotemporal (CNV3)

- Greater auricular (C2,3)

B, buccal nerve; EN, external (dorsal) nasal nerve; IO, infraorbital nerve; IT,

infratrochlear; ST, supratrochlear nerve; M, mental nerve; SO, supraorbital nerve; Zf,

zygomaticofacial nerve; ZT, zygomaticotemporal nerve.

Adapted from: Simplified Facial

Rejuvenation. 1st ed. Heidelberg: Springer; 2008.

Innervation of nose

3 Cranial Nerves

  • CN 1 olfaction

  • CN 5 general sensation / Anterior V1 / Posterior V2

  • Glands : parasympathetic fibres in CN 7

Sympathetic nerve fromT1 spinal cord

4 Paranasal Sinuses


a. Supraorbital and supratrochlear nerve


  • V1 --> anterior and posterior ethmoidal branches

  • V2 --> orbital branch from pterygopalatine ganglion

  • Lessor and greater palaytine nerve

Maxillary: most common site of chronic sinusitis

  • Infraorbital and alveolar branches of V2


  • Posterior ethmoidal branch of V1

  • Orbital branch of V2 from pterygopalatine ganglion

Blood supply of spinal cord:

Arterial supply is through:

  • Anterior spinal artery

  • Posterior spinal artery

  • Segmental arterial supply from radicular / medullary arteries.


3.7.5 Describe potential neurobiological mechanisms for:




  • Peripheral sensitivity - pericranial myofascial tissues

  • Central - sensitisation of second-order neurone at the dorsal horn

  • Genetic basis

  • Relationship with psychological stress, anxiety and depression (descending inhibition)



  • Cortical spreading depression - a wave of sustained depolarization (neuronal inactivation) moving through intact brain tissue. Likely triggers inflammatory responses

  • Hyperexcitable cortex - The lower threshold for occipital cortex excitations (?genetic)

  • Changes in periaqueductal grey over time with iron deposition

  • Increased white matter lesions

  • Activation of trigeminovascular complex (meningeal receptors)

  • Calcitonin Gene related peptide -

Facial Pain


  • PIFP does not have a specific cause however injury to the trigeminal nerve proximally or distally may lead to this disorder

  • Demyelination may initiate

  • Infectious causes can also be considered

  • Hyperactive central neuronal activity may contribute

  • Hypofunctioning dopaminergic pathways may also contribute

Orodental pain


  • Current mechanisms are controversial

  • Psychological factors play a role however are unlikely to be initiating factors

  • Deafferentation of the trigeminal sensory fibres is most likely mechanism but not confirmed

Reference: Bosch-Aranda, M. L., Vázquez-Delgado, E., & Gay-Escoda, C. (2011). Atypical odontalgia: a systematic review following the evidence-based principles of dentistry. CRANIO®, 29(3), 219-226.

Cluster headache


  • Reflex activation of the trigeminovascular system, which innervates cranial vessels and dura mater, synapse in the trigeminocervical complex.

  • Activation of the trigeminovascular system also activates the superior salivatory nucleus in the pons

  • Cells within this nucleus also control the parasympathetic autonomic vasodilator pathway.

  • Activation of the parasympathetic pathways may cause a further reflex arc back through the trigeminal autonomic reflex arc relayed through the sphenopalatine ganglion


3.7.6 Discuss the pathophysiology of trigeminal neuralgia


  • Idiopathic (10%) - Unknown - nothing found

  • Classic (60%) - Neurovascular compression in the trigeminal root entry zone

  • Secondary (30%) - Tumours or artery malformations / MS relationship


  • Disease-related e.g. MS

  • Peripheral - Progressive dystrophy of peripheral branches of trigeminal nerve evoked by compression syndrome

  • Allergic-immune reaction processes causing dystrophy

  • Possibly also changes to voltage-gated sodium channels with ectopic activity effects

  • Central - Peripheral factors cause change to afferent signal with pathological paroxysmal irritation focus with ectopic discharge


3.7.7 Discuss the pathophysiology of:

Post-traumatic headache

Pathophysiology is not clear. Theories include:

  • Impaired descending modulation

  • Neurometabolic changes (local cellular injury and unregulated ion-exchange neurotransmitter release)

  • Trigeminal sensory system activation - Neuroinflammatory CNS changes

Post-craniotomy headache

Pathogenesis is unclear

  • Meningeal inflammation

  • Nerve entrapment

  • Adhesion of muscle to the dura or other mechanisms

  • Neuroma formation

  • Destruction from drilling

Presenting features

  • Immediate postoperative headache may occur in up to 80% of craniotomy

  • Most resolve within 7 days

  • Unrelated to tumour size

  • More common in females

  • Up to 25% develop chronic (>3 months) headache

  • Posterior fossa procedures, sub occipital craniotomies for acoustic neuromas

  • Modification of operative procedure may help reduce risk

Factors that decrease the risk

  • Early NSAID use

  • The surgical technique to minimise muscle injury

  • Fat grafting with dura closure

  • Local anaesthetic use in wound

  • Perioperative gabapentinoid may help

  • Postoperative depression has an association with developing the headache


  • Botox?

  • Triptans

  • Non-pharm - TENS, physiotherapy, acupuncture, CBT, stress management techniques, supportive neck collars

  • GON blocks and nerve stimulation (Strong evidence)

  • Radiofrequency or cryoablation (though the risk of pain aggravation)

Post-dural puncture headache

  • The theory is reduced CSF pressure with loss of cushioning of the brain in the intracranial fluid. Also possibly stretch on blood vessels within the brain

  • Munroe-Kelly doctrine - Secondary dilatation of the venous system


3.7.8 Perform a cranial nerve examination and fundoscopy / TMJ / cervical spine


3.7.11 Detail the critical factors for assessing life-threatening headache

Red flag headache features include:


  1. New-onset headache over 50 yo


  1. Subacute and/or progressive headaches that worsen over time

  2. New or uncharacteristic headache

  3. Any headache of maximum severity at onset

  4. Increase in headache severity or frequency

Associated symptoms

  1. Persistent headache precipitated by valsalva

  2. Systemic features e.g. headache, myalgias, weight loss

  3. Related illness e.g. history of cancer

  4. Neurological signs

  5. Seizures


3.7.12 Demonstrate awareness of potential causes of headache that may be overlooked on initial assessment including:

Idiopathic intracranial hypertension (Pseudotumour cerebri syndrome or BIH)


  • Requires all CAUSES of raised ICP to be excluded

  • More common in women and obesity

  • OCP is a risk factor


  • Headache

  • Visual loss (peripheral initially then later central)

  • Tinnitus (often pulsatile)

  • Nausea and vomiting


  • Neuro-ophthalmological work up

  • Examination of the fundi for papilledema and visual field testing

  • MRI brain and MRI venography

  • Possibly LP - with CSF with opening pressures


  • Medication - Acetazolamide

  • LP to lower pressure

  • Stenting of transverse sinus stenosis (previously CSF shunt)

  • Weight loss

Low CSF pressure (intracranial hypotension)

(Spontaneous intracranial hypotension)


  • Secondary headache caused by CSF leak or CSF-venous fistula involving the nerve root sheath

  • Female predominant in 40-50s


  • Possibly the hydrostatic indifference point (where the upper and lower CSF pressures are equal) moves lower down


Traumatic, post-traumatic. Can be dural leaks of fistulae


  • Abrupt onset daily persistent orthostatic headache that improves in the supine position

  • People can often report the exact date and time this began

  • Location is usually bifrontal/occipital or upper cervical but can be everywhere

  • Can present with neurological symptoms like tinnitus, photophobia, dizziness etc.


  • MRI findings

  • Myelography can be considered


  • Epidural blood patch can be effective

Post-craniotomy headache

(As above)


  • Occurs in 2/3rds of patients undergoing a craniotomy


  • Trauma to tissue, muscles, bone or meninges

  • Nerve injury

  • Debris from drilling bone irritating internal structures of meninges

  • Muscle adherence to dura mater

  • Formation of neuroma in surgical scar

  • Central sensitisation

  • Aberrant nerve regeneration

Risk factors

  • Neurosurgery > 4 hrs

  • Craniectomies


  • Continuous, pulsatile or pounding pain of variable intensity within 7 days of surgery


  • Similar to other headaches

  • Nothing specific

Reference: Subbarao BS, Fernández-de Thomas RJ, Eapen BC. Post Craniotomy Headache. [Updated 2021 Aug 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:

Pathology in the eyes and ears

Ophthalmologic - Consider

  • Acute narrow-angle glaucoma (Headache, vision changes, nausea and vomiting. Eye red)

  • Corneal abrasions/Foreign body (generally identified history. Watch for keratitis)

  • Giant cell arteritis (older, with PMR)

  • Intraocular tumours (Rare cause)

  • Optic neuropathy (usually with colour loss)

  • Dry eye (often tearing and redness)

  • Orbital vascular lesions (worse with Valsalva type factors)

Reference: Fiore, D. C., Pasternak, A. V., & Radwan, R. M. (2010). Pain in the quiet (not red) eye. American family physician, 82(1), 69-73.

Otalgic causes - Consider

  • Auricular cellulitis

  • Auricular trauma

  • Foreign body in ear

  • Herpes zoster (Ramsay Hunt Syndrome)

  • Acute otitis externa

Space-occupying lesions


  • The most common presenting sign is a headache

  • Worst symptom in 50% of cases

Risk factors

  • Trauma

  • HIV infection

  • Diabetes

  • Malignancy

  • Tuberculosis


  • Dull and constant

  • Occasionally throbbing in nature

  • Intracranial pressure rising maneuvers often cause pain to worsen

  • Headaches with nausea and vomiting should be a red flag

  • Abnormal neurology with headache is also a concern

  • May be associated with seizures

  • Behavioural changes may be noted

Vascular disease

General Types

  • Cerebral ischaemic events

  • Non-traumatic intracranial haemorrhage

  • Unruptured vascular malformation

  • Arteritis (e.g. giant cell)

  • Cervical carotid or vertebral artery disorder

  • Pituitary apoplexy


  • Acute in onset

  • Usually throbbing or thunderclap peaking rapidly

  • Not always associated with other symptoms and signs

Types with detail

  • Subarachnoid haemorrhage (Aneurysm rupture in 85%)

  • CNS vasculitis (Headache is insidious but commonly stroke is the outcome)

  • Cervical artery dissection (Stroke in young people. Avg onset 44yrs. Headache and neck pain. Headache can be insidious but hard to differentiate otherwise)

  • Cerebral venous thrombosis (More common in young and female. Usually other clotting risk factors. Severe headache otherwise non-specific)

Reference: Lu J, Liu W, Zhao H, Headache in cerebrovascular diseases

Stroke and Vascular Neurology 2020;5:doi: 10.1136/svn-2020-000333

Sinus pathology (Headache attributed to disorder of the nose and paranasal sinuses)


  • The presence of nasal autonomic symptoms is a hallmark differentiating these conditions

  • Chronic sinus pathology has been shown to be linked with persistent headaches

Diagnosis criteria/features - Acute

  • Headache in temporal relationship with the onset of rhinosinusitis

  • Worsened with rhinosinusitis

  • Worse with pressure

  • Unilaterality

Diagnostic criteria/features - Chronic

  • Headache developed in temporal relation to chronic rhinosinusitis

  • Headache waxes and wanes in parallel with the degree of sinus congestion

  • Headache exacerbated by pressure over paranasal sinuses

  • Unilateral - headache is also unilateral

Temporomandibular dysfunction

Three main types


  • Congenital malocclusion

  • Post-traumatic

  • Ankylosis (e.g. RA, OA)

NB: Only 3-5 % of TMJ patients have surgically amenable lesions


  • Occlusal disorders (malocclusion, bruxism)

  • Secondary muscle spasm (can be helped with splints, Physio, TCAs. Regular analgesics and relaxants have pitfalls)

Myofascial pain of masticatory muscles

  • Common

  • Multifactoral triggers

  • Depression and personality disorder traits

  • Associations with tension myalgia (fatigue, fragmented sleep)

  • 72% have oral habits (e.g. clicking)


  • Attend to mechanical disorder / correct malocclusion (Dental review)

  • Arrest abnormal habits

  • Relaxant therapy (physical, psychological)

  • Pain therapies - but be careful

  • Botox in refractory cases

  • Surgical consideration

  • (Avoid SSRIs because of risk yawning triggering)

  • Tricyclics and anti-inflammatories (if suitable)

  • Diet and healthy lifestyle


3.7.13 Distinguish between the clinical features of the following PRIMARY chronic daily headache syndromes

Migraine (with and without aura)


  • 17% of females and 6 % of males (In US)

  • Incidence of general migraine peaks at 5 yo in males and 12-13 in females

  • Incidence of migraine with aura is a bit older (12-13 M 14-15 F)

  • Lower socioeconomic status is associated with migraine


  • Headache, throbbing, unilateral, nausea, photophobia, phonophobia, worse with movement

  • One-third of patients do NOT have throbbing pain


  • Vascular was thought to be the cause as 'throbbing' no known it is not that simple - called a neurovascular condition

  • Cortex is hyperexcitable and migraine patterns are genetically determined

  • Modern imaging suggests vascular changes are NOT linked to pain


  • Cortical spreading depression - a wave of sustained depolarization (neuronal inactivation) moving through intact brain tissue. Likely triggers inflammatory responses

  • Hyperexcitable cortex - Lower threshold for occipital cortex excitations (?genetic)

  • Changes in periacqueductal gray over time with iron deposition

  • Increased white matter lesions

Differential diagnosis features

  • Less than 15 days = episodic

  • Greater than 15 days = chronic (8 of the 15 days must be clearly migrainous)

Less than four hours - short duration

  • Cluster headache


  • Paroxysmal hemicrania

  • Hypnic headache

  • Primary stabbing headache

Longer than four hours - long duration

  • Chronic migraine

  • Chronic tension-type headache

  • Hemicrania continua

  • New daily persistent headache

Associated conditions

  • Epilepsy (benign rolandic epilepsy, benign childhood epilepsy)

  • Familial dyslipoproteinaemias

  • Hereditary haemorrhagic telangiectasia

  • Tourette syndrome

  • Hereditary essential tremor

  • Hereditary cerebral amyloid angiopathy

  • Depression

  • Anxiety

  • Asthma

  • Patent foramen ovale

  • Stroke (migraine with aura is a risk factor for stroke particularly cerebellar)

Transformed (Chronic) migraine


  • Headache (tension-type or migraine-like) on >15 days/month for > 3 months

  • Occurring in a patient who has had >5 attacks of migraine with or without aura

  • On >8 days/month for > 3 months

Risk factors

  • Attack frequency

  • Acute medication overuse

  • Duration of disease

  • Obesity and snoring

  • Stressful life events

  • Female gender

  • Lower education and socioeconomic status

  • Head injury

Factors to REVERT from chronic to episodic migraine

  • Adherence to migraine prophylactic drugs

  • Withdrawal of overused migraine abortive drugs

  • Physical exercise

  • Absence of cutaneous allodynia

  • Lower baseline headache frequency

Cluster headache and variants

Referred Neuralgias and Vascular Fascial pain

  • Neuralgia (clues from history)

  • Vascular (often from associated symptoms - vasomotor, visual, flushing)

  • Cluster (Rhinorrhoea, lacrimation, conjunctival injection)

Cluster headache

  • Usually male in 3rd or 4th decades

  • Headache is severe and usually unilateral

  • Throbbing - cranial/orbital/facial

  • Associated conjunctival redness, eye-watering & lacrimation

  • The attack may last 30 minutes to 4 hours - several times a day over a 6-8 week period

  • Can be transient Horner's syndrome - persists in 10% of cases

  • Cluster headache may be precipitated by trauma

  • High rates of suicide

SUNCT syndrome

Short lasting, Unilateral, Neuralgiform headache with Conjunctival injection and Tearing

Attacks of moderate or severe unilateral headache pain lasting seconds to minutes at least once a day with lacrimation and red eye

Often a series of stabs

(Another option is SUNA - which does NOT have conjunctival injection and lacrimation)

Paroxysmal Hemicrania

  • Attacks of severe, unilateral pain that is orbital, supraorbital, temporal or any combination of these

  • 2-30 mins

  • Several times a day

  • Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, mitosis, ptosis and/or eyelid oedema.

  • Responds to indomethacin

Hemicrania Continua

Persistent, unilateral headache with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, mitosis, ptosis, restlessness and agitations. SENSITIVE TO INDOMETHACIN


3.7.14 Distinguish between the clinical features of the following SECONDARY chronic daily headache syndromes


  • Medication overuse headache - Regular use of acute or symptomatic medication on 10 or more (opioid/triptan) or 15 (simple analgesia) or more days per month. Usually resolves when medication overuse is stopped

  • Multiple substances possible, not just medications

  • Medication-induced side effects (Headache attributed to substance or its withdrawal) - Difficult to prove irrefutably. Headache needs to occur temporally and then cease with avoidance/removal of the substance


  • Headache attributable to neck injury or whiplash


  • Malfunction of descending serotonergic pain inhibitory system

  • Neurochemical dysregulation

  • Activation of the trigeminal system by vertebrae C2 to C5 afferents by the convergence of trigeminal and cervical afferents in the spinal dorsal horn and consecutive sensitisation of CNS

  • Psychological factors also heavily contribute


  • Proper patient education

  • Support of normal movement

  • Avoiding immobilisation

  • Resumption of work

  • Targeted physiotherapy

Reference: Obermann, M., Naegel, S., Bosche, B., & Holle, D. (2015). An update on the management of post-traumatic headache. Therapeutic advances in neurological disorders, 8(6), 311–315.

Disorders of intracranial pressure

Increased intracranial pressure

  • Usually associated with other neurological symptoms and papilloedema/neck stiffness

  • Headache in the morning, visual obscuration, vomiting with little nausea

  • Causes include Idiopathic ICH, ICH due to metabolic, toxic, or hormonal causes, hydrocephalus, chromosomal problem (e.g. Down syndrome)

Decreased intracranial pressure

  • Orthostatic headache often with neck pain, tinnitus, hearing and photophobia, and nausea.

  • Headache on standing with improvement when lying down

  • No visual changes on change of posture and minimal nausea

  • Causes include: post lumbar / dural puncture, spontaneous leak

Headache referred from other structures

  • Tension-type headache

Similar triggers to migraine - some overlap

  • Stress

  • Menstruation

  • Strong odours

  • Sleep fragmentation / sleep lack

  • Weather change

  • Missing meal

  • Exertion

  • Dehydration

Similar triggers to migraine

  • 65% Photophobia in tension headache

  • 65% sonophobia in TH

  • 75% neck pain in patients with migraine!

  • More kinesiophobia in migraine

Key differences

Cervicogenic headache

This is said to be problematic terminology. The likely anatomical location of nociception is the cervical spine - likely the zygapophyseal joints through pathogenesis is unclear. Management similar to tension-type headaches


3.7.15 Recognise the clinical features of

Trigeminal neuralgia

  • A brief shock-like pains

  • Abrupt in onset and termination

  • Limited to a distribution of one or more of the trigeminal nerve

  • Triggered by innocuous stimuli

  • Pain may become more severe over time

  • No neurological deficits!

  • Can cause muscle movements - Tic doloureux

  • May have some mild autonomic features

  • Following paroxysm - usually a quiescent time where it cannot be triggered again

Other cranial neuralgias

Glossopharyngeal neuralgia

  • Unilateral brief stabbing pain abrupt in onset and termination in the glossopharyngeal, auricular and/or pharyngeal branches of the vagus nerve

  • Pain can be in the ear, tongue, tonsillar fossa, or below the angle of the jaw

  • Worsened by yawning, swallowing, talking, or coughing

  • Treatment is commonly surgical - glossopharyngeal and upper vagal root section

Occipital neuralgia

  • Unilateral brief stabbing pain abrupt in onset and termination in the distribution of the greater, lesser and/or third occipital nerves- often with dysaesthesia and tenderness

Geniculate neuralgia (Nervus intermedius neuralgia)

  • Same but felt in the ear

  • Lancinating pain of the 7th cranial nerve

  • Treatment similar to trigeminal neuralgia

Post-herpetic neuralgia

  • Preceding vesicles (commonly but not always)

  • Older age at onset

  • Constant

  • Can have sensory triggers

  • Treatment: Antivirals, steroids, TCAs, anticonvulsants, gabapentin or pregabalin

“Burning mouth” syndrome

  • Condition of older women (50-70)

  • Etiology/pathophysiology remains unclear

  • Primary and Secondary types (nutritional deficiencies, dental-related trauma, hormonal (menopause), endocrine (diabetes).


  • Tongue is most common site followed by hard palate, gingiva and lower lips

  • Pain is worst in the mornings

  • Relaxation, chewing gums, drinking cold drinks can all help

  • Usually symmetrical and bilateral

  • Pain worsens over the day

  • Xerostomia may play a role with reduced salivary gland secretion noted


  • No consensus on cause so treatment is difficult

  • Addressing psychosocial is important as patients often don't feel validated

  • Simple measures such as avoiding triggers (e.g. acids) and helping to relieve dry mouth (e.g. crushed ice and gum)

  • Capsaicin can be trialled but epigastric pain is often a problem

  • Topical clonazepam has been trialled but the minimal benefit

  • Low dose TCA and oral clonazepam can be trialled

  • Psychological therapy is essential


3.7.16 Apply a differential diagnosis approach to determining the anatomical origin of 'atypical' facial pain

Start with: What is TYPICAL facial pain?

  • Cranial arteritis

  • Cluster headache

  • Post-herpetic neuralgia

  • Trigeminal neuralgia

  • Etc.

What is Atypical facial pain?

  • Atypical facial pain (Now persistent idiopathic facial pain) is a persistent facial pain that does not have the characteristics of cranial neuralgias and is not attributable to another disorder

Presenting features

  • Facial pain occurs daily and persists throughout the day

  • Limited to one particular side of the face at onset, deep and poorly localised, no sensory or neurological deficits. Investigations do not show a cause.

  • Commonly occurs in areas of the trigeminal nerve but does not fit other criteria

  • Usually unilateral without autonomic features

  • Duration is long-lasting most of the day

  • Often may have a triggering event

Epidemiology / Risk factors

  • Females more commonly

  • Often psych or mood disorder

  • Ill-defined pattern

  • Sometimes related to sinuses


  • Likely neuropathic pain

  • Maxillary artery migraine variant


  • ICH3 requires more than 2 hrs per day over more than 3 mths

  • Lots of terms - all unhelpful generally (myofascial pain, facial arthromyalgia, somatodynia, atypical odontalgia etc)

Post-traumatic Trigeminal pain

  • Usually from dental surgery

  • 80% recover within one year

  • Rarely a posterior fossa tumour or vertebral artery aneurysm


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