Facial pain (prosopalgia) is a clinical term that combines all pain syndromes localized in the facial region. Prosopalgia can be neurogenic, vascular, symptomatic, myogenic, psychogenic and atypical. During the diagnosis, on the basis of the characteristics of the pain phenomenon, the type of prosopalgia is established; to identify its cause, an ophthalmological, otolaryngological, neurological, dental, and psychological examination is performed. Depending on the type and etiology of prosopalgia, anti-inflammatory, antihistamine, corticosteroid, sedative and psychotropic pharmaceuticals are used in the treatment.
Prosopalgia is a collective clinical concept that combines all pain syndromes that occur in the face. The complex anatomical and functional organization of the facial structures and the nervous system of this area determines the variety of pathogenetic mechanisms for the appearance of pain.
Among the latter, compression, inflammatory, reflex can be distinguished. The great individual significance of the face and increased attention to this part of the human body causes the frequent occurrence of prosopalgia of psychogenic origin. The neurotic component is often superimposed on any pathological processes in the facial area, which should certainly be taken into account in the treatment of facial pain of various nature. Due to its variable etiology, prosopalgia is the subject of supervision by doctors of various clinical specializations - neurology, otolaryngology, ophthalmology, dentistry, psychiatry.
An inflammatory reaction can act as an etiological factor in facial pain. Most often, prosopalgia of inflammatory origin occurs with sinusitis. It can be observed in otitis media, ophthalmic diseases (iridocyclitis, uveitis, conjunctivitis, keratitis, corneal ulcer), TMJ arthritis, have odontogenic etiology (pulpitis, periodontitis). Prosopalgia can occur with inflammatory lesions of the vessels of the facial region, for example, with Horton's disease. Often, inflammatory etiology has neurogenic prosopalgia with neuralgia of the glossopharyngeal nerve, trigeminal nerve, Oppenheim's syndrome, ganglionitis of the pterygopalatine ganglion, ganglioneuritis of the geniculate ganglion.
On the other hand, neurogenic prosopalgia can have a compression genesis, i.e., occur as a result of compression of the nerve trunks or nodes due to a change in the relative position of the anatomical structures of the facial region, narrowing of the bone and intermuscular nerve canals, the development of tumor formations, etc. Compression etiology can have vascular prosopalgia, such as carotidynia from carotid artery compression.
The reflex mechanism of the occurrence of pain syndrome is often realized in odontogenic and neurogenic facial pain. The cause of prosopalgia in such cases is pathological reflex impulses coming from chronic infectious foci. An example is neuralgia of the ear node. Myogenic prosopalgia of reflex genesis occurs with myofascial syndromes in the neck and shoulder girdle. Other causes of myogenic prosopalgia may be TMJ dysfunction (Costen's syndrome), bruxism, myofascial syndrome in masticatory muscles.
Prosopalgia of psychogenic origin often occurs in suspicious, emotionally labile people against the background of overwork, chronic psycho-emotional discomfort, or as a result of an acute stressful situation. Often, psychogenic prosopalgia is observed in people with hysterical neurosis, neurasthenia, and depressive neurosis. It can occur within the framework of such psychiatric diseases as schizophrenia, psychopathy, manic-depressive psychosis.
In some cases, prosopalgia is iatrogenic. So, Oppenheim's syndrome can occur after ophthalmic operations; Extraction of teeth and other dental interventions can provoke the development of dental plexalgia or atypical odontalgia. One of the causes of neurogenic facial pain is damage to the nerve structures during operations in the facial region. In addition, a number of facial pains do not have a well-established etiology. For example, cluster headache, atypical prosopalgia, chronic paroxysmal hemicrania.
Facial pains are classified mainly according to the mechanism of development. Allocate prosopalgia:
Vascular facial pain includes:
Neurogenic prosopalgia includes:
Symptomatic facial pain . Depending on the etiology, symptomatic prosopalgia is divided into
Atypical include pain that does not fit into the clinic of any of the types of prosopalgia indicated in the classification. Often they are caused by a combination of several pathogenetic mechanisms and have a psychogenic component.
Facial pains of various origins differ in their clinical features regarding the nature, duration, paroxysmality, autonomic staining of the pain syndrome. These distinctive features, as well as accompanying symptoms (if any), enable the neurologist to determine the type of prosopalgia, which is of fundamental importance in the diagnosis and subsequent treatment of facial pain.
The permanent (permanent) type of pain syndrome is more typical for myogenic, psychogenic and symptomatic prosopalgia. It can occur with episodes of increasing and decreasing pain. Paroxysmal pain phenomenon with intense pain attacks of variable duration against the background of complete or almost complete absence of pain in the interictal period is typical for neurogenic and vascular prosopalgia. A distinctive feature of the latter is the presence of a pronounced vegetative component - during paroxysm, swelling, lacrimation, hyperemia of the skin area, rhinorrhea, nasal congestion, redness of the conjunctiva, etc. are observed.
Bilateral character, as a rule, has symptomatic, myogenic and psychogenic prosopalgia. Moreover, the latter may differ in the asymmetry of the pain phenomenon in the halves of the face. Vascular, neurogenic, and atypical facial pains are usually unilateral.
Irradiation of pain is more typical with neurogenic and vascular prosopalgia, but can also be observed with facial pain of symptomatic origin. In addition, symptomatic prosopalgia is often reflex in nature. The most illustrative example is odontogenic prosopalgia, caused by the occurrence of pain in the Zakharyin-Ged zones: mandibular, nasolabial, maxillary, fronto-nasal, temporal, sublingual, chin, laryngeal. Each zone is a reflection of the pathology of certain teeth, while toothache may be absent.
In most cases, facial pain is not a diagnosis in itself, but only a syndrome. In this regard, it is important to identify / exclude the underlying disease that caused prosopalgia. In the course of diagnosis by a neurologist-algologist, a thorough study of the various characteristics of the pain phenomenon, palpation of the muscles of the face, identification of trigger points (places of intense palpation pain) is carried out. The exclusion / confirmation of the symptomatic nature of facial pain is carried out with the participation of an ophthalmologist, dentist, otolaryngologist.
If necessary, X-ray of the tooth, orthopantomogram, X-ray of the paranasal sinuses and temporomandibular joint, otoscopy and pharyngoscopy, measurement of intraocular pressure, examination of eye structures, etc. are performed. In order to identify inflammatory changes, a clinical blood test is prescribed. Psychogenic and atypical prosopalgia are an indication for consultation with a psychiatrist or psychotherapist with psychological testing and pathopsychological examination.
Therapy of facial pain depends entirely on its etiology. Symptomatic prosopalgia primarily requires the treatment of the underlying disease - otitis, sinusitis, pulpitis, etc. In inflammatory genesis, neurogenic, vascular and myogenic prosopalgia are treated by prescribing anti-inflammatory pharmaceuticals (diclofenac, indomethacin, ibuprofen, nimesulide, etc.).
To relieve pain at trigger points, therapeutic blockades with the introduction of corticosteroids and local anesthetics can be performed. With trigeminal neuralgia, the use of carbamazepine is effective, with ganglionitis - ganglion blockers (benzohexonium, pentamine), with Horton's disease - corticosteroids (prednisolone). For anti-inflammatory purposes, physiotherapeutic methods are additionally used: hydrocortisone ultraphonophoresis, DDT, magnetotherapy, electrophoresis.
Therapy of facial pain of compression genesis, in addition to anti-inflammatory treatment, includes vascular (nicotinic acid, aminophylline) and decongestants (antihistamines, diuretics), vitamins gr. B. Failure of conservative therapy is an indication for surgical treatment (eg, microsurgical decompression of the trigeminal nerve). Persistent prosopalgia in ganglioneuritis is an indication for removal of the affected ganglion, in trigeminal neuralgia in such cases, the measure of temporary relief of pain is radiofrequency destruction of the trigeminal nerve root.
In many cases, an obligatory component of the treatment of facial pain is sedative therapy: soothing herbal preparations, mild tranquilizers (mebicar), antidepressants (St. John's wort extract, fluvoxamine, sertraline). If necessary, vegetotropic agents are prescribed ( belladonna alkaloids + phenobarbital, belladonna extract). Therapy of psychogenic prosopalgia is carried out by methods of psychotherapy and psychotropic drugs selected in accordance with clinical characteristics: tranquilizers, antipsychotics, antidepressants. Electrosleep and darsonvalization are shown.