Craniofacial pain

Screen for trigeminal autonomic cephalgias - cluster, paroxysmal hemicrania, hemicrania continua, short lasting unilateral neuralgiform headache with conjunctival injection (SUNCT), short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)

Pain is paroxysmal in nature, sharp/stabbing/throbbing and severe (cluster, PH, SUNCT/SUNA)

Mild to moderate baseline pain with exacerbations of pain (HC)

Pain is most severe in ophthalmic branch of trigeminal nerve

Eye redness, miosis, tearing, eyelid swelling, nasal congestion/rhinorrhea, forehead/face sweating

Attack Frequency (per day):

Attack duration:

Anxiety/restlessness/agitation (all TAC’s)

Circadian periodicity (cluster, typically 1-2 cycles per year, each cycle may last up to 12 weeks, often occurs around same time of the day)

Migrainous of nausea, photophobia, phonophobia (common with cluster and hemicrania continua)

Screen for trigeminal neuralgia

Stereotyped paroxysms of pain in mandibular and/or maxillary branches of trigeminal nerve (Pain should not involve mandible of jaw, posterior part of external ear, or posterior third of the scalp (C2 dermatome))

Duration of each attack: 1 second – 2minutes followed by refractory period

Continuous aching/numbness/tingling pain in the jaw/teeth in-between attacks (reported in 50%)

Trigger zones present (Around nose, mouth, nasolabial fold)

Autonomic symptoms (reported in 30%)

Pain triggered by non-noxious stimulation (talking, chewing, water, air, pillow, etc.) (allodynia, reported in 99% of TN)

History of facial trauma, dental/maxillo-facial/neuro-surgical procedures (post-traumatic/post-surgical etiology)

Associated facial numbness without history of trauma/surgery? (increased likelihood of secondary etiology)

Screen for secondary causes of trigeminal neuralgia and mimics

Screen for glossopharyngeal neuralgia

Unilateral brief stabbing pain at base of tongue, tonsils, beneath angle of jaw, inside ear (Pain provoked by talking, swallowing, coughing)

Globus/foreign body sensation in throat

Cough, hoarse voice, unexplained syncope (vagus nerve involvement)

Medications tried

Cluster: Oxygen, subcutaneous sumatriptan, nasal Zolmitriptan, Lidocaine nasal spray, Lithium, Verapamil, melatonin, sub-occipital steroid injection, trans-cutaneous VNS

PH/HC: Indomethacin (1st line), celecoxib, gabapentin, topiramate, verapamil, melatonin, occipital nerve block

SUNCT/SUNA: Lamotrigine (1st line) topiramate, gabapentin, carbamazepine, oxcarbazepine, duloxetine, melatonin

Trigeminal neuralgia: Carbamazepine/Oxcarbazepine (1st line), Lamotrigine, Baclofen, Gabapentin

Post-herpetic neuralgia: 1st line: Gabapentin, Pregabalin, Carbamazepine, Phenytoin

Glossopharyngeal neuralgia: Carbamazepine/Oxcarbazepine (1st line), Lamotrigine, Baclofen, Gabapentin

Workup

Brain MRI w/wo obtained? (structural abnormalities of trigeminal nerve, spinal trigeminal nucleus abnormalities in medulla/pons, CP angle tumor, vascular loop compression, pituitary abnormalities)

MRA head/neck obtained? (carotid/vertebral dissection, cavernous sinus aneurysm)

MRV obtained? (cavernous sinus thrombosis)

Other diagnostics