Management of the patient with facial pain

Diagnosis and management of facial pain are reviewed. Causes of facial pain are divided into three groups: a) trigeminal-autonomous headaches: cluster headache, paroxismal hemicrania and SUNCT; b) headache secondary to alteration of cranial, sinusal, maxillary and ophthalmic structures; y c) trigeminal and glossopharyngeal neuralgia and neuropathic pain. Diagnostic criteria based on the classification of the International Headache Society (IHS) are defined, as well as further explorations, mainly neuro-imaging and cranial CT and MR. Pain secondary to ophthalmic, sinusal and maxillary pathologies will require specific treatments of ophthalmology, ORL, odontology and maxillofacial surgery, respectively. Within the medical treatment, drugs such as indomethacin, corticoids, sumatriptan, verapamil and lithium are the most effective in the first group. Anti-epileptics are the most effective anti-neuralgic drugs: carbamazepine, oxcarbamazepine, hydantoins, lamotrigine, gabapentin and topiramate. Neurosurgical treatments play a relevant role in neuralgias and a potential role in chronic trigeminal-autonomous pain refractory to medical treatment. The method of percutaneous analgesia is indicated for aged patients or patients with high anesthetic risk. Antineuralgic results of intracranial approach and vascular microdecompression are the most effective and persistent, but with the risk associated to any neurosurgical procedure. Therapeutic options for the management of neuropathic pain are diverse, which suggest its difficult management, including anti-depressants, anti-epileptics, opioids, anesthetics and other drugs. © 2003 Sociedad Española del Dolor. Published by Arán Ediciones, S.L.