Clinical aspects of neurological disease

Facial pain

Neurological diagnosis

• History and examination

• Site of lesion

• Pathology

• Differential diagnosis

• Plan of investigation

• Management

Multiple sclerosis

• Inflammatory demyelinating disease of the CNS

• Prevalence 100/100 000 in UK

• Latitudinal gradient

• Aetiology: Genetic susceptibility / environmental factor

MS: Symptoms and signs

• Optic nerves

• Cervical cord

• Brainstem

• Periventricular white matter

MS: Symptoms and signs

• Loss of vision

• Weakness and sensory loss

• Loss of bladder and bowel control

• Double vision

• Dysarthria and dysphagia

• Loss of balance

• Fatigue

MS: Diagnosis

• History and examination

• MRI• Visually Evoked

Responses• Lumbar puncture

• Clinical evidence of more than one lesion disseminated in time

• Laboratory evidence of more than one lesion

• Inflammation within the CNS

MS: Disease Course

• Relapsing remitting

• Progressive

Cerebrovascular disease

• Thrombosis

• Haemorrhage

Risk factors

• Hypertension

• Ischaemic heart disease, peripheral vascular disease

• Diabetes mellitus

• Smoking

• Cholesterol

Facial pain

• Age/sex

• Site of pain

• Nature of pain

• Special features

• Aggravating factors

• Relieving factors

Causes of facial pain

• Trigeminal neuralgia

• Atypical facial pain

• Migraine

• Post-herpetic neuralgia

Trigeminal neuralgia

• Location of pain : V2 and V3

• Mouth-ear zone (60%), nose-orbit zone (30%)

• V1 involved in less than 5% of cases

• Quality of pain: ‘red hot needles’

• Excruciating pain lasting for a few seconds

• Followed by unpleasant aching pain

TGN symptoms

• Pain is not continual

• Triggering factors: chewing, smiling, yawning (motor), hot and cold fluids, brushing teeth, draught on face (cutaneous)

• Diurnal variation - attacks at night rare

TGN Natural History

• Increasing frequency of attacks

• Recurrent attacks more disabling

• Most patients over 60 years except in multiple sclerosis

• Used as a diagnostic pointer in people under 45 years

TGN Treatment

• Medical: Carbamazepine, Gabapentin, Phenytoin

• Surgical neurovascular decompression

• Stereotactic thermocoagulation of the ganglion

Atypical facial pain

• Maxillary

• Deep, burning, continual

• Behind ear, on to neck, across to opposite maxillary area i.e. crosses anatomical boundaries

• Often clutch their face

• Treatment with antidepressants

Facial migraine

• Retro-orbital pain

• Throbbing

• Associated features: Nausea, photophobia, phonophobia

• Previous history of migraine

• Mainly in women ages 25 to 50

Cluster headache

• Severe pain

• Localises around eye

• ‘Alarm clock’ headache

• Conjunctival injection, miosis, ptosis

• Rhinorrhoea

Postherpetic neuralgia

• Ophthalmic herpes occurs in the elderly

• 30% develop postherpetic neuralgia

• Continual dull burning pain

• Triggered by touching the eyebrow or brushing the hair

• May remit after 12-18 months

• Very distressing with a high suicide risk

Case History

• 47 year old Algerian man

• 7 year history of right facial pain

• Jabbing pain triggered by touching his lip

• Treated with Carbamazepine

• Depressed

• No abnormal signs on examination

Case history (2)

• Outpatient MRI of brain

• Large tortuous vessels surrounding the right trigeminal nerve

• Requires angiography before intervention

Conclusions

• Careful history taking is essential to correctly diagnose facial pain

• Remember the anatomy of the trigeminal nerve

• Many facial pain syndromes are wrongly attributed to disease of the teeth or sinuses