Chronic Facial Pain
 

Facial Pain

What is facial pain?

Facial pain is a catchall term for any type of pain in the face. Facial pain can be either acute or chronic. Acute pain is pain that lasts less than six months. Acute pain usually resolves either on its own or with treatment. Examples are sinusitis, infections of the mouth or gums, or injuries to the face, such as a black eye or broken nose. Chronic facial pain is pain that either lasts continuously for over six months or occurs on a fluctuating basis over a period of six months or longer. Examples are trigeminal neuralgia and temporomandibular joint disorder.

 

Is there a cure for facial pain?

Typically, there are no cures for chronic facial pain. Healthcare providers and their patients focus on management of the chronic pain. Chronic pain management has two broad goals:

 

  • Reduce symptoms to the extent possible

  • Reduce the emotional distress and functional impairments that are associated with the symptoms

The first goal involves reducing pain and any other symptoms associated with facial pain. The second goal is two-fold: to reduce the fear, anger, anxiety, depression or sleep problems that tend to go along with living with chronic facial pain, and reducing the sense of disability that tends to occur with pain.  Overall, these goals amount to assisting the patient to live well, work, and be involved in life, despite having some chronic pain symptoms.  

 

The healthcare system has different ways it pursues chronic pain management. Broadly speaking, there are three different types of chronic pain clinics in our healthcare system: 

 

  • Pain clinics that focus on surgical and/or interventional procedures (surgeries, injections, nerve-burning procedures, and the like)

  • Pain clinics that focus on long-term medication management (such as long-term use of narcotic pain medications)

  • Pain clinics that focus on chronic pain rehabilitation (such as interdisciplinary chronic pain rehabilitation programs)

All three types of clinics treat chronic facial pain.

 

There are different types of chronic facial pain. The most common are trigeminal neuralgia and temporomandibular joint disorder.  

 

Trigeminal neuralgia

Trigeminal neuralgia (TN) is a pain disorder that affects the face, usually on one side. The pain is related to the trigeminal nerve, which runs from the brain to the side of the face.  

 

The pain of trigeminal neuralgia is often intense and short-lived. Patients often describe the pain as electrical in quality. While often the pain occurs in a burst that lasts for seconds, sometimes the pain can occur in repetitive bursts that lasts for hours to days. The intermittent frequency of pain can often lead patients to a persistent sense of vigilance and alarm in anticipation of the next burst of pain. This combination of intermittent pain and persistent fear can lead to difficulties with coping. In turn, these difficulties can lead to impairments, such as staying home from work or other activities as a way of attempting to cope with it all.

 

There is no single cause of TN. Moreover, the known possible causes are not clearly defined. It is thought that compression of the trigeminal nerve by an enlarged blood vessel can cause it. It is also associated with aging. Multiple sclerosis is also sometimes associated with TN. Central sensitization may also play a role in the progression of TN. Hu, W. H., Zhang, K., & Zhang, J. G. (2010). Atypical trigeminal neuralgia: A consequence of central sensitization? Medical Hypotheses, 75, 65-66. Watson, J. C. (2007). From paroxysmal to chronic pain in trigeminal neuralgia: Implications of central sensitization. Neurology, 69, 817-818. Central sensitization is a highly reactive state of the nervous system, which amplifies pain. It can occur with most any pain disorder.

 

Therapies & procedures

Common treatments for TN are anticonvulsant medications, neuroablation procedures, surgery, and chronic pain rehabilitation programs. 

 

Anticonvulsant Medications

Anticonvulsant medications, particularly carbamazepine, is typically a first-line treatment. A Cochrane Review concluded that carbamazepine is effective in reducing TN pain. Wiffen P. J., Derry S., Moore R. A., McQuay, H. J. (Updated September 15, 2011). Carbamazepine for acute and chronic pain in adults. In Cochrane Database Reviews, 2011, (1). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. Gabapentin, another anticonvulsant medication, may also reduce the pain of TN. Moore, R. A., Wiffen P. J., Derry S., & McQuay, H. J. (Updated February 16, 2011). Gabapentin for chronic neuropathic pain and fibromyalgia in adults. In Cochrane Database Reviews, 2011, (3). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. However, the long-term efficacy of these medications remains largely unknown.

 

Yang, et al., Yang, M., Zhou, M., Chen, N., & Zakrzewska, J. M. (Updated April 30, 2010). Non-epileptic drugs for trigeminal neuralgia. In Cochrane Database Reviews, 2011, (1). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. reviewed clinical trials for other medications, which are not anticonvulsants. They found clinical trials only for tizanidine, tocainide, and pimozide. They concluded that none of these medications provide substantial benefit over carbamazepine. 

 

Neuroablation Procedures & Surgeries

Zakrzewska and Akram Zakrzewska, J. M., & Akram, H. (Updated May 13, 2010). Neurosurgical interventions for the treatment of classical trigeminal neuralgia. In Cochrane Database Reviews, 2011, (9). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. reviewed clinical trials of different neuroablation procedures as well as decompression surgeries. They found no clinical trials for decompression surgeries, despite how commonly they are done. In terms of neuroablation procedures, they concluded that established clinical trials showed reductions in pain, though sensory side effects were common. They also observed that the published clinical trials were of poor quality and often demonstrated bias.  

 

Chronic Pain Rehabilitation Programs

Failing to obtain sufficient pain reduction through the use of medications or surgical/interventional procedures, patients with TN often seek care in chronic pain rehabilitation programs. TN pain can easily lead to suffering in terms of emotional distress and functional impairments. Carlson, C. R. (2007)  Psychological factors associated with orofacial pain. Dental Clinics of North America, 51, 145-160. Chronic pain rehabilitation programs are designed to reduce such distress and impairments for patients with any type of chronic pain, including TN. They are effective in doing so, and there is high quality research evidence demonstrating this effectiveness. Gatchel, R., J., & Okifuji, A.  (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793. However, there are no clinical trials assessing the effectiveness of chronic pain rehabilitation programs solely for TN. 

 

Temporomandibular joint disorder

Temporomandibular joint disorder (TMJ) is a pain disorder that occurs in the joints of the jaws, on either side of the face. Specifically, it occurs in the joints located in front of the ears, where the lower jaw joins the face. The pain is usually described as a tension-related ache, though in more advanced stages, it can sometimes be a sharp pain.  

 

The cause of pain is due to orthopedic changes of the jaw from persistent wear and tear. The wear and tear is usually associated with stress-related clenching and tension of the jaw muscles. It can also sometimes start with a trauma to the jaw joints.

 

Therapies & Procedures

Common treatments for TMJ are biofeedback, cognitive behavioral therapies, anti-inflammatory medications, antidepressant medications, bite guards or occlusal adjustments, botox injections, surgical procedures, and chronic pain rehabilitation programs.

 

Biofeedback

Biofeedback is a method of teaching patients to reduce the chronic jaw muscle tension that leads to TMJ. In their meta-analysis, Crider and Glaros Crider, A. B., & Glaros, A. G. (1999). A meta-analysis of EMG biofeedback treatment of temporomadibular disorders. Journal of Orofacial Pain, 13, 29-37. determined that biofeedback was effective in reducing TMJ pain. Indeed, they found that 69% of patients who underwent biofeedback were symptom free after treatment.

 

Cognitive behavioral therapies

Cognitive behavioral therapy (CBT) is a collection of therapies delivered by a psychologist. CBT essentially teaches patients ways to reduce pain, reduce the emotional distress associated with pain, and reduce the impact that pain has on their lives. In a clinical trial, Litt, et al., Litt, M. D, Shafer, D. M., & Kreutzer, D. L. (2010). Brief cognitive-behavioral treatment of TMD pain:  Long-term outcomes and moderators of treatment. Pain, 151,110-116.  doi:10.1016/j.pain.2010.060.030 randomized 101 men and women into either standard care or standard care with cognitive behavioral therapy. Standard care was defined by use of splints, a diet of soft foods, and anti-inflammatory medications. They found that the group with cognitive behavioral therapy had significantly less pain, less depressive symptoms, and less interference in their lives by pain, particularly for those who had a high readiness or motivation for treatment.  

 

Turner, et al., Turner, J. A., Mancl, L. & Aaron, L. A. (2006). Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial. Pain, 121, 181-194. randomly assigned 79 patients with TMJ to cognitive behavioral therapy and 79 patients with TMJ to a control group who underwent an educational class. At one-year follow-up, patients in the cognitive behavioral therapy group had significantly better improvements on all measures. For example, half the cognitive behavioral group had at least 50% improvement in pain. Less than a third of the control group had such improvement. The cognitive behavioral therapy group reported no interference from their TMJ at a rate three times higher than the control group.  

 

Anti-inflammatory medications

There are few data that supports the effectiveness of anti-inflammatory medications for TMJ pain. Lauren & Dionne Lauren, E. T. & Dionne, R. A. (2004). Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: A randomized placebo-controlled comparison of celecoxib to naproxen. Pain, 111, 13-21. showed that naproxen reduced pain significantly better than either celecoxib or a placebo.  

 

Antidepressant medications

There is a lack of well-designed research supporting the use of antidepressant medications for the pain of TMJ. Their use tends to be supported because of their demonstrated effectiveness with other chronic pain disorders. The only published randomized clinical trial of an antidepressant looked at the use of amitriptyline. Rizatti-Barbosa, et al., Rizatti-Barbosa, C. M., Nogueira, M. T., de Andrade, E. D., Ambrosano, G. M., & de Barbosa, J. R. (2003). Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders. Cranio, 21, 221-225. found that amitriptyline was significantly better than placebo in reducing pain. However, the trial was very small and the medication was used only for two weeks. Consequently, it is hard to make generalizations to how effective it is in actual clinical practice.  

 

Bite guards or occlusal adjustments

In their Cochrane review, Koh and Robinson Koh, H., & Robinson, P. G. (Updated November 12, 2002). Occlusal and adjustment for treating and preventing temporomandibular joint disorders. In Cochrane Database Reviews, 2003, (1). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. reviewed 660 published articles on the use of bite guards, only six of which were clinical trials. Upon their review of these six clinical trials, they concluded that bite guards provide no benefit over the comparison or control groups.

 

Botox injections

In a double-blind, placebo-controlled clinical trial, Nixdorf, et al., Nixdorf, D. R., Heo, G., & Major, P. W. (2002). Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain, 99, 465-473. found no difference in pain or other measures between patients who were treated with botox injections and those who were treated with an injection filled with placebo.  

 

Surgeries

In their Cochrane review, Rigon, et al., Rigon, M., Pereira, L. M., Bortoluzzi, M. C., Loguercio, A. D., Ramos, A. L. & Cardosa, J. R. (Updated April 10, 2010). Arthroscopy for temporomandibular joint disorders. In Cochrane Database Reviews, 2011, (5). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience. reviewed all published outcome studies for surgery related to TMJ. They found seven clinical trials. They found that there was no difference in any outcome measure, including pain, between those patients getting surgery and those who did not get surgery.

 

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog.

 

References

Last Updated on Friday, 23 October 2015 15:45

Published on Friday, 27 April 2012 13:37

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