{"product_id":"understanding-orofacial-pain-a-complete-guide-to-constant-and-attack-like-facial-pain-syndromes","title":"Understanding Orofacial Pain: A Complete Guide to Constant and Attack-Like Facial Pain Syndromes","description":"\u003cp\u003eChronic facial pain that isn't caused by dental problems is a highly disabling but often underdiagnosed condition that affects thousands of patients. This comprehensive review, published in the journal \u003cem\u003eCephalalgia\u003c\/em\u003e, explains that orofacial pain syndromes fall into three main categories: attack-like conditions (including neuralgias and facial variants of headaches), persistent pain disorders (including neuropathic pain and persistent idiopathic facial pain), and other conditions like temporomandibular disorders that can overlap with headaches. The authors emphasize that many of these syndromes can be effectively treated with medications that neurologists already commonly use for other pain conditions, and that proper diagnosis requires close collaboration between dental and neurological specialists.\u003c\/p\u003e\n\n\u003ch1\u003eUnderstanding Orofacial Pain: A Complete Guide to Constant and Attack-Like Facial Pain Syndromes\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#introduction\"\u003eIntroduction: Why This Research Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#diagnosing\"\u003eHow Orofacial Pain Syndromes Are Diagnosed\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#attack-like\"\u003eAttack-Like Orofacial Pain Conditions\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#neuralgias\"\u003eCranial Neuralgias\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#facial-migraine\"\u003eFacial Presentations of Primary Headaches\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#facial-tacs\"\u003eFacial Trigeminal Autonomic Cephalalgias (TACs)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#short-lasting\"\u003eFacial Variants of Short-Lasting Primary Headaches\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#first-bite\"\u003eFirst Bite Syndrome\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#eagle\"\u003eEagle Syndrome (Stylohyoid Syndrome)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#persistent\"\u003ePersistent Orofacial Pain\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ptnp\"\u003ePost-Traumatic Trigeminal Neuropathic Pain (PTNP)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#pifp\"\u003ePersistent Idiopathic Facial Pain (PIFP)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#pidap\"\u003ePersistent Idiopathic Dentoalveolar Pain (PIDAP)\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#burning-mouth\"\u003eBurning Mouth Syndrome\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#tmd\"\u003eTemporomandibular Disorders and Bruxism\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#sinus\"\u003eSinus Pain and Dental Pain\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#clinical-implications\"\u003eClinical Implications: What This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of This Review\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eChronic orofacial pain is a real neurological condition, not psychosomatic.\u003c\/li\u003e\n\u003cli\u003eICOP provides clear diagnostic criteria for orofacial pain syndromes.\u003c\/li\u003e\n\u003cli\u003eMany orofacial pain syndromes respond to medications like amitriptyline, gabapentin, pregabalin, carbamazepine, and duloxetine.\u003c\/li\u003e\n\u003cli\u003eAvoid unnecessary dental procedures; they can worsen neuropathic or idiopathic pain.\u003c\/li\u003e\n\u003cli\u003eClose collaboration between dentists, neurologists, and pain specialists is essential for accurate diagnosis and management.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"introduction\"\u003eIntroduction: Why This Research Matters\u003c\/h2\u003e\n\n\u003cp\u003eClinicians would never accept a vague diagnosis of \"just headache\" because treatment depends critically on identifying the specific type of headache syndrome. The International Classification of Headache Disorders (ICHD-3) has been remarkably successful in providing robust clinical criteria that define headache syndromes, leading to scientific and treatment advances.\u003c\/p\u003e\n\n\u003cp\u003eNeurologists are rightly the primary specialists that patients consult for headache—pain in the first division of the trigeminal nerve—since the neurological examination is essential for distinguishing primary from secondary headaches. However, pain conditions affecting the second and\/or third branches of the trigeminal nerve pose significant diagnostic and management difficulties for neurologists due to their heterogeneous nature.\u003c\/p\u003e\n\n\u003cp\u003eChronic orofacial pain that has no dental cause is certainly underdiagnosed and definitely undertreated. One reason why we don't recognize chronic orofacial pain as a neurological disease—with the possible exception of trigeminal neuralgia—is that we know so little about its mechanisms and have as yet no specific treatment to offer. The consequence is often a life-long odyssey for affected patients without a correct diagnosis.\u003c\/p\u003e\n\n\u003cp\u003eAs a result, management of orofacial pain conditions is frequently unsuccessful and risks irreversible harm to the patient. Indeed, orofacial pain and its many facets cannot be reduced to trigeminal neuralgia or persistent idiopathic (formerly called atypical) facial pain. We need to see orofacial pain syndromes as independent and distinct trigeminal disorders that deserve recognition in the headache field.\u003c\/p\u003e\n\n\u003ch2 id=\"diagnosing\"\u003eHow Orofacial Pain Syndromes Are Diagnosed\u003c\/h2\u003e\n\n\u003cp\u003eOrofacial pain (OFP) syndromes are diagnosed based on the criteria outlined in the International Classification of Orofacial Pain (ICOP), which was developed to work in harmony with the current headache classification, ICHD-3. Due to the interdisciplinary nature of orofacial pain disorders, the ICOP has been developed collaboratively by dentists, pain specialists, and neurologists to seek consensus among specialties, and it has been endorsed by the International Headache Society.\u003c\/p\u003e\n\n\u003cp\u003eFor example, the recent definitions of trigeminal neuralgia and temporomandibular disorder (TMD) are identical in both classifications, avoiding different definitions for the same disease. ICHD-3 and ICOP can therefore be cited equally, but given that ICOP is more specific for orofacial pain, it should be favored.\u003c\/p\u003e\n\n\u003cp\u003eA close interaction between dental and neurological specialists is necessary for diagnosing such diseases. Dentists primarily exclude dental and other oral causes, while neurologists or orofacial pain specialists, on the basis of this exclusion, diagnose the specific facial pain and treat the patient. Trigeminal neurophysiology (somatosensory evoked potentials or SEP) and neuroimaging of the head (CT and MRI scans) may be needed based on the same principles as in headache diagnosis.\u003c\/p\u003e\n\n\u003cp\u003eJust like in the diagnostic workup of headache disorders, diligent history taking and neurological examination are key to finding the right diagnosis—and therefore the right treatment—in non-dental facial pain.\u003c\/p\u003e\n\n\u003ch2 id=\"attack-like\"\u003eAttack-Like Orofacial Pain Conditions\u003c\/h2\u003e\n\n\u003cp\u003eIf pain in the orofacial area occurs in clearly described attacks, there may still be a dental cause such as a \"cracked tooth\" or pulpitis. However, a non-dental pain condition is also possible, and neurologists should be aware of the relevant conditions. Broadly speaking, attack-like facial pains are subdivided into neuralgias and orofacial variants of headache syndromes.\u003c\/p\u003e\n\n\u003cp\u003eNeuralgias can affect most cranial nerves, with the trigeminal, occipital, and glossopharyngeal nerve being the most common. The clinical characteristics of these conditions vary significantly, and proper diagnosis is essential for effective treatment.\u003c\/p\u003e\n\n\u003ch2 id=\"neuralgias\"\u003eCranial Neuralgias\u003c\/h2\u003e\n\n\u003ch3\u003eTrigeminal Neuralgia\u003c\/h3\u003e\n\n\u003cp\u003eIn contrast to most other orofacial pain syndromes, cranial neuralgias are well-defined clinical syndromes with broad consensus among clinicians. As a result, diagnostic criteria have been harmonized in both ICHD-3 and ICOP, and clear guidelines for clinical management have been developed.\u003c\/p\u003e\n\n\u003cp\u003eDue to some similarities in presentation, the most common cranial neuralgia—trigeminal neuralgia—is often misdiagnosed as dental pulpitis. It is not uncommon for patients with trigeminal neuralgia to have received invasive but ineffective dental treatment before the correct diagnosis is identified. The authors of this review refer readers to an excellent and exhaustive review on trigeminal neuralgia that has recently been published, as their focus is on the lesser-known orofacial pain syndromes.\u003c\/p\u003e\n\n\u003ch2 id=\"facial-migraine\"\u003eFacial Presentations of Primary Headaches\u003c\/h2\u003e\n\n\u003cp\u003eThe clinical borders between headache and orofacial pain are often blurred. Migraine and other primary headaches may extend to the maxillary dermatome (V2), sometimes even to the mandibular dermatome (V3) of the trigeminal nerve. Some patients experience an isolated facial migraine—defined as attacks fulfilling the criteria for migraine located exclusively in the V2\/V3 dermatomes.\u003c\/p\u003e\n\n\u003cp\u003eThe signs and symptoms follow the diagnostic criteria of the eponymous headache syndromes. Facial manifestations of a primary headache present as three distinct types:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eType 1:\u003c\/strong\u003e Primary headache that spreads into the face\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eType 2:\u003c\/strong\u003e Orofacial pain which seems to have replaced a former headache but maintained the same clinical phenotype\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eType 3:\u003c\/strong\u003e De-novo orofacial pain that resembles the primary headache phenotype without any involvement of the ophthalmic trigeminal branch\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe prevalence of each subtype remains unclear and is probably frequently misdiagnosed and underreported. Isolated orofacial pain replicating headache (type 3) seems rarer, and in this specific and complex presentation, underreporting due to misdiagnosis is even more likely.\u003c\/p\u003e\n\n\u003ch3\u003eOrofacial Migraine\u003c\/h3\u003e\n\n\u003cp\u003eMigraine is probably the first primary headache that ignited interest in the relationship between head pain and facial pain. The fact that migraine involves orofacial structures was already noted by Harold Wolff in 1963. Without clear diagnostic criteria, various terms were assigned over the years, such as orofacial migraine, lower-half migraine, or migraine with isolated facial pain.\u003c\/p\u003e\n\n\u003cp\u003eApplying the ICOP criteria, series of patients presenting with migraine as isolated facial pain have recently been published. Although the spread of headache to the face is certainly not rare, isolated migraine in the face is rather uncommon.\u003c\/p\u003e\n\n\u003cp\u003eThe presentation of isolated V2 migraine, often throbbing, accompanied by mild rhinorrhea (runny nose), and pain on head movement, may additionally lead to misdiagnosis as sinusitis. As a general rule, facial presentations of migraine are associated with later age at onset, and aura is absent or at least less common. The authors note that neither chronic facial migraine nor facial medication-overuse headache (MOH) has been described as yet.\u003c\/p\u003e\n\n\u003ch2 id=\"facial-tacs\"\u003eFacial Trigeminal Autonomic Cephalalgias (TACs)\u003c\/h2\u003e\n\n\u003cp\u003eTACs can present in the orofacial region (V2 and\/or V3). These findings align with reports of \"lower face cluster\" headache, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) presenting equally in all trigeminal dermatomes. Even the facial variant of paroxysmal hemicrania has been reported.\u003c\/p\u003e\n\n\u003cp\u003eAutonomic symptoms may vary in facial TAC, which raises the question of how specific symptoms such as conjunctival injection (redness of the eye) and tearing are for the diagnosis of TAC, or whether these autonomic signs are more specific for involvement of the ophthalmic division of the trigeminal nerve.\u003c\/p\u003e\n\n\u003ch2 id=\"short-lasting\"\u003eFacial Variants of Short-Lasting Primary Headaches\u003c\/h2\u003e\n\n\u003cp\u003eReports of orofacial variants of primary headache types other than migraine and cluster headache occur with an unclear prevalence. An orofacial variant of idiopathic stabbing headache has been reported.\u003c\/p\u003e\n\n\u003cp\u003eA very peculiar new entity is constant unilateral facial pain with additional attacks (CUFPA). In this condition, the constant dull pain is intercepted with distinct non-neuralgic pain attacks of a completely different pain character and without any accompanying symptoms. These attacks last 10–30 minutes and occur between two and 20 times per day.\u003c\/p\u003e\n\n\u003cp\u003eThese attacks distinguish this type of side-locked facial pain from persistent idiopathic facial pain (PIFP), which is defined as constant orofacial pain without any other positive or negative features and without attacks.\u003c\/p\u003e\n\n\u003ch3\u003eTreatment of Facial Primary Headache Variants\u003c\/h3\u003e\n\n\u003cp\u003eThe treatment of a primary headache manifested as orofacial pain is similar to the corresponding primary headache. For example, an orofacial migraine is treated like a migraine, and an orofacial cluster headache is treated like a cluster headache.\u003c\/p\u003e\n\n\u003cp\u003eWhile there may be subtle differences between a primary headache and its orofacial counterpart—such as the prevalence of aura or associated symptoms—no data exist on whether medications are more or less effective in orofacial variants of primary headaches. The publication of ICOP with its clear criteria will facilitate standardized trials to compare these types.\u003c\/p\u003e\n\n\u003ch2 id=\"first-bite\"\u003eFirst Bite Syndrome\u003c\/h2\u003e\n\n\u003cp\u003eFirst bite syndrome (FBS) is an unusual but very memorable orofacial pain syndrome characterized by severe and piercing pain in the parotid region (the area around the salivary gland in front of the ear) that eponymously occurs with the first bite of each meal and improves with subsequent bites.\u003c\/p\u003e\n\n\u003cp\u003eThe pathophysiology has been attributed to an unbalanced sympathetic\/parasympathetic innervation of the parotid gland. The syndrome is mostly seen following surgery of the parotid or parapharyngeal region. The pain lasts seconds to a few minutes.\u003c\/p\u003e\n\n\u003cp\u003eThis syndrome is sometimes misdiagnosed as atypical trigeminal neuralgia, but sodium channel blockers are largely ineffective. In contrast, botulinum toxin injections and medications used for the treatment of neuropathic pain are generally useful. However, since the syndrome is rather rare, there is no consensus regarding treatment of FBS, as evidence is limited to case reports and case series.\u003c\/p\u003e\n\n\u003cp\u003eA typical differential diagnosis is salivary gland pain due to sialadenitis (inflammation of the salivary gland). Although a rare disorder, patients with first bite syndrome are likely to consult a neurologist or general practitioner rather than a dentist, making it important for these clinicians to recognize the condition.\u003c\/p\u003e\n\n\u003ch2 id=\"eagle\"\u003eEagle Syndrome (Stylohyoid Syndrome)\u003c\/h2\u003e\n\n\u003cp\u003eEagle syndrome is a rare disease characterized by unilateral neuralgiform pain usually in the pharynx, tongue, and jaw, triggered by jaw opening, swallowing, and neck rotation. Eagle himself described two types of this syndrome:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eClassic type:\u003c\/strong\u003e The cranial nerves are directly or indirectly irritated by the elongated styloid process after tonsillectomy\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCarotid type:\u003c\/strong\u003e The carotid arteries are impinged by the ossified stylohyoid ligament, and the irritated nerve plexus leads to the facial and head pain\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eRepeated compression of the carotid artery may result in cerebrovascular complications. Neurological complications encompass aneurysm, dissection, occlusion of the internal and more rarely the external carotid arteries, transient ischemic attack, cerebral infarction, and sudden death due to mechanical irritation of the carotid sinus.\u003c\/p\u003e\n\n\u003cp\u003eWhen a patient complains of oropharyngeal pain in association with neck and jaw movement, digital palpation of the tonsillar fossa is recommended. If there is an elongated styloid process, a bony structure may be palpable that triggers the pain and discomfort. Diagnosis of Eagle syndrome should be established with imaging modalities.\u003c\/p\u003e\n\n\u003cp\u003eDifferential diagnoses include idiopathic cranial neuralgias, migraine and TACs, temporomandibular disorders, ear, nose, and throat (ENT) diseases, and space-occupying lesions.\u003c\/p\u003e\n\n\u003ch3\u003eTreatment of Eagle Syndrome\u003c\/h3\u003e\n\n\u003cp\u003eThere is no established strong evidence for treatment of Eagle syndrome, and the treatment strategy should be discussed based on the seriousness of the patient's symptoms. Styloidectomy (surgical removal of the styloid process) is probably the method of choice, and if necessary, carotid stenting should be considered in patients with neurological signs.\u003c\/p\u003e\n\n\u003cp\u003eHowever, surgical procedures are not always efficient, and first-line drugs including pregabalin, gabapentin, and duloxetine are recommended for the pain.\u003c\/p\u003e\n\n\u003ch2 id=\"persistent\"\u003ePersistent Orofacial Pain\u003c\/h2\u003e\n\n\u003cp\u003eWhen non-dental orofacial pain is persistent and not attack-like, in principle two types exist: the pain is either accompanied with somatosensory changes (for example, post-traumatic trigeminal neuropathic pain, PTNP) or not accompanied by such changes (persistent idiopathic facial pain, PIFP).\u003c\/p\u003e\n\n\u003ch2 id=\"ptnp\"\u003ePost-Traumatic Trigeminal Neuropathic Pain (PTNP)\u003c\/h2\u003e\n\n\u003cp\u003eIf somatosensory changes occur, these characteristically appear directly in the painful area and can be either negative (hypesthesia, or reduced sensation, and hypoalgesia, or reduced pain perception) or positive (allodynia, where normally non-painful stimuli cause pain, and hyperalgesia, where painful stimuli cause exaggerated pain) or both.\u003c\/p\u003e\n\n\u003cp\u003eHence the old name \"anaesthesia dolorosa\" describing persistent pain following surgical nerve damage. Trigeminal neuropathic pain is persistent and dull\/pressing in quality. Superimposed neuralgic pain paroxysms may occur, but these are not the predominant pain type.\u003c\/p\u003e\n\n\u003cp\u003eProbably the best-known sub-form of trigeminal neuropathic pain is postherpetic neuralgia, which is usually easy to diagnose due to the pathognomonic efflorescence (characteristic skin rash) in the distribution of one or more branches of the trigeminal nerve, and consequently treated by neurologists or pain therapists.\u003c\/p\u003e\n\n\u003cp\u003eThe clinical picture of neuropathic pain and PIFP is nearly identical, although the pain character in neuropathic pain is more often described as \"burning.\" It seems that in most cases PIFP ceases at night, and this may be an additional discrepancy between these two conditions.\u003c\/p\u003e\n\n\u003cp\u003eAdditionally, the pain location of PIFP may shift over the years and even cross to the other side, which is per definition not seen in neuropathic pain since the latter is elicited by damage to the affected peripheral nerve.\u003c\/p\u003e\n\n\u003ch2 id=\"pifp\"\u003ePersistent Idiopathic Facial Pain (PIFP)\u003c\/h2\u003e\n\n\u003cp\u003ePersistent idiopathic facial pain, formerly called atypical facial pain, is defined as a constant facial pain with a dull, aching, or nagging quality, poorly localized and not following the distribution of a specific branch of the trigeminal nerve. Patients do not describe a neuralgiform, sharp-shooting pain component.\u003c\/p\u003e\n\n\u003cp\u003eMaximum pain intensity is described mostly over the cheekbone and the upper jaw. Most PIFP patients describe a subjective swelling over the affected region, attributed to central mismatch or perceptual distortion. While initially the pain is unilateral, with increasing duration it may cross the midline.\u003c\/p\u003e\n\n\u003cp\u003eClinical and radiographic examinations in PIFP patients are normal and do not show local causes. If the pain is localized exclusively to a dentoalveolar site such as teeth and dentoalveolar bone, it is classified as persistent idiopathic dentoalveolar pain (PIDAP), formerly called atypical odontalgia.\u003c\/p\u003e\n\n\u003ch3\u003eThe Diagnostic Challenge\u003c\/h3\u003e\n\n\u003cp\u003eIt can be difficult to distinguish PIFP from painful post-traumatic trigeminal neuropathy. Many patients with persistent orofacial pain report a dental intervention or trauma around the time of pain onset. The key question is whether the orofacial pain is the result of dental pathosis or not.\u003c\/p\u003e\n\n\u003cp\u003eUnfortunately, patients frequently have difficulties in reconstructing the sequence of events. The resulting difficulty in disentangling the causality of the orofacial pain, and the fact that these patients primarily consult dentists, lead to root-canal treatment or extraction of healthy teeth—even though tooth extractions (which effectively denervate the dental nerve fibers) carry a high risk of aggravating the situation further.\u003c\/p\u003e\n\n\u003cp\u003eThe combination of constant pain without objective findings frequently leads to the incorrect suggestion that the condition is the mere expression of a psychosomatic disorder, which adds weight to the psychological burden. This situation is reminiscent of that of a migraine patient 30 years ago. As a result, patients frequently move from specialist to specialist without receiving adequate diagnosis or treatment.\u003c\/p\u003e\n\n\u003ch3\u003eWhat Causes PIFP?\u003c\/h3\u003e\n\n\u003cp\u003eThe underlying cause of PIFP remains unclear. Considering that the pain does not follow the action of a peripheral nerve, a central nervous system origin has been suggested. The clinical characteristics of PIFP and PIDAP are consistent with the recently introduced pain category: \u003cstrong\u003enociplastic pain\u003c\/strong\u003e, for which the underlying mechanisms are not completely understood but include an augmented pain response characterized by centrally altered sensory processing and pain modulation.\u003c\/p\u003e\n\n\u003cp\u003eThis can appear either in solitude or as a mixed-pain state also involving components of nociceptive and neuropathic pain. Part of the clinical picture is multifocal pain; co-morbidity between chronic pains is frequent. In line with this, PIDAP was recently proposed to be a chronic overlapping pain condition (COPC), although this attribution needs more clinical data.\u003c\/p\u003e\n\n\u003ch2 id=\"pidap\"\u003ePersistent Idiopathic Dentoalveolar Pain (PIDAP)\u003c\/h2\u003e\n\n\u003cp\u003ePIDAP is characterized by constant pain localized to one tooth or a dentoalveolar site, without any spread even after tooth removal. The pain characteristics are similar to PIFP but limited to a single tooth location. Like PIFP, the clinical and radiographic examinations are normal and do not show local causes.\u003c\/p\u003e\n\n\u003cp\u003eTreatment approaches for PIDAP mirror those for PIFP, including medications such as amitriptyline, gabapentin, pregabalin, carbamazepine, and duloxetine. Non-steroidal anti-inflammatory drugs (NSAIDs) may be used for acute pain, though their effectiveness is limited for this condition.\u003c\/p\u003e\n\n\u003ch2 id=\"burning-mouth\"\u003eBurning Mouth Syndrome\u003c\/h2\u003e\n\n\u003cp\u003eBurning mouth syndrome is a persistent orofacial pain condition characterized by a burning sensation in the tongue, lower lip, and hard palate mucosa. Patients often experience xerostomia (dry mouth) and dysgeusia (altered taste), as well as exaggerated responses to hot and spicy foods and drinks.\u003c\/p\u003e\n\n\u003cp\u003eTreatment options include topical clonazepam and capsaicin, though evidence is limited to case reports and series. Cognitive behavioral therapy may also be helpful for some patients.\u003c\/p\u003e\n\n\u003ch2 id=\"tmd\"\u003eTemporomandibular Disorders and Bruxism\u003c\/h2\u003e\n\n\u003cp\u003ePainful temporomandibular disorders (TMD) and bruxism (teeth grinding) are important differential diagnoses in orofacial pain. These conditions may interfere with, trigger, or overlap with headache disorders. The definitions of TMD are now identical in both ICHD-3 and ICOP classifications, reflecting the collaborative effort between dental and neurological specialties.\u003c\/p\u003e\n\n\u003cp\u003eTMD pain is typically located in the muscles of mastication, the temporomandibular joint, or both, and is often aggravated by jaw function such as chewing or yawning. Bruxism, which involves clenching or grinding of teeth, can contribute to muscle pain and headache.\u003c\/p\u003e\n\n\u003ch2 id=\"sinus\"\u003eSinus Pain and Dental Pain\u003c\/h2\u003e\n\n\u003cp\u003eSinus pain is a common misdiagnosis for facial presentations of migraine. The presentation of isolated V2 migraine, often throbbing, accompanied by mild rhinorrhea, and pain on head movement, may lead to misdiagnosis as sinusitis. Patients may undergo unnecessary sinus treatments or surgeries before the correct diagnosis of migraine is established.\u003c\/p\u003e\n\n\u003cp\u003eDental pain, including pulpitis and cracked tooth syndrome, must always be excluded by dental examination before a diagnosis of non-dental orofacial pain is made. However, unnecessary dental interventions on healthy teeth are a significant problem in patients with neuropathic or idiopathic orofacial pain.\u003c\/p\u003e\n\n\u003ch2 id=\"clinical-implications\"\u003eClinical Implications: What This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eThis review has several important implications for patients suffering from chronic facial pain:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRecognition matters:\u003c\/strong\u003e Chronic orofacial pain syndromes are real neurological conditions, not psychosomatic disorders. Just as migraine was once dismissed as \"all in the head,\" PIFP and related conditions deserve recognition and appropriate treatment.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eClassification improves care:\u003c\/strong\u003e The International Classification of Orofacial Pain (ICOP) provides clear diagnostic criteria that help clinicians identify specific orofacial pain syndromes, leading to more targeted and effective treatment.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTreatment options exist:\u003c\/strong\u003e Many orofacial pain syndromes respond to medications commonly used by neurologists for other pain conditions, including amitriptyline, gabapentin, pregabalin, carbamazepine, and duloxetine.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAvoid unnecessary dental procedures:\u003c\/strong\u003e Patients with non-dental orofacial pain frequently undergo root canal treatments or tooth extractions that not only fail to relieve pain but may actually worsen the condition by causing additional nerve damage.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMultidisciplinary approach is essential:\u003c\/strong\u003e Close collaboration between dentists, neurologists, and pain specialists is necessary for accurate diagnosis and effective management of orofacial pain.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of This Review\u003c\/h2\u003e\n\n\u003cp\u003eThe authors acknowledge several limitations in the current understanding of orofacial pain syndromes:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eThe prevalence of facial presentations of primary headaches remains unclear and is probably underreported due to misdiagnosis.\u003c\/li\u003e\n  \u003cli\u003eNo data exist on whether medications are more or less effective in orofacial variants of primary headaches compared to their cranial counterparts.\u003c\/li\u003e\n  \u003cli\u003eNeither chronic facial migraine nor facial medication-overuse headache has been described as yet.\u003c\/li\u003e\n  \u003cli\u003eFor rare conditions such as first bite syndrome and Eagle syndrome, evidence is limited to case reports and case series, with no consensus regarding optimal treatment.\u003c\/li\u003e\n  \u003cli\u003eThe inconclusive electrophysiological results in PIFP may result from the limited field testing of the ICOP criteria, and different pathologies may lead to similar clinical presentations.\u003c\/li\u003e\n  \u003cli\u003eThe attribution of PIDAP as a chronic overlapping pain condition (COPC) needs more clinical data.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations for Patients\u003c\/h2\u003e\n\n\u003cp\u003eIf you are experiencing chronic facial pain, here are important steps to consider:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStart with a dental examination:\u003c\/strong\u003e Your dentist should first exclude dental causes such as pulpitis, cracked tooth syndrome, or temporomandibular disorders. Be cautious about agreeing to invasive dental procedures if no clear dental pathology is identified.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSeek a neurologist or orofacial pain specialist:\u003c\/strong\u003e If dental causes are excluded and pain persists, consult a neurologist or an orofacial pain specialist who is familiar with the ICOP classification.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKeep a pain diary:\u003c\/strong\u003e Document when pain occurs, its duration, quality (throbbing, stabbing, burning, dull), location, and any triggering factors. This information is invaluable for accurate diagnosis.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDescribe your pain precisely:\u003c\/strong\u003e Note whether pain occurs in attacks or is constant, whether it is triggered by specific activities (chewing, swallowing, neck rotation), and whether you experience any accompanying symptoms such as runny nose, tearing, or sensitivity to light and sound.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eBe patient with treatment:\u003c\/strong\u003e Finding the right medication may take time. Medications such as amitriptyline, gabapentin, pregabalin, carbamazepine, and duloxetine may take several weeks to show full effectiveness.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eConsider a second opinion:\u003c\/strong\u003e If you have undergone multiple dental procedures without pain relief, or if you have been told your pain is \"psychological,\" seek a second opinion from a specialist familiar with orofacial pain syndromes.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk about imaging:\u003c\/strong\u003e If Eagle syndrome is suspected, ask about appropriate imaging studies to evaluate the styloid process.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eRemember that chronic orofacial pain is a recognized medical condition with effective treatment options. You are not alone, and help is available from specialists who understand these complex pain syndromes.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is persistent idiopathic facial pain (PIFP)?\u003c\/h3\u003e\n\u003cp\u003ePIFP is constant facial pain that is dull, aching, or nagging, poorly localized, and not following a specific nerve branch. It is not accompanied by sensory changes. The cause is unclear, but it may involve central nervous system changes. It is a recognized neurological condition, not psychological.\u003c\/p\u003e\n\u003ch3\u003eHow is orofacial pain diagnosed?\u003c\/h3\u003e\n\u003cp\u003eDiagnosis starts with a dental exam to exclude dental causes. Then a neurologist or orofacial pain specialist uses the International Classification of Orofacial Pain (ICOP) criteria. History, neurological exam, and sometimes imaging or nerve tests help identify the specific syndrome. Collaboration between dental and neurological specialists is essential.\u003c\/p\u003e\n\u003ch3\u003eWhat treatments are available for orofacial pain?\u003c\/h3\u003e\n\u003cp\u003eMany orofacial pain syndromes respond to medications neurologists commonly use for other pain conditions, such as amitriptyline, gabapentin, pregabalin, carbamazepine, and duloxetine. For first bite syndrome, botulinum toxin injections and neuropathic pain medications may help. Treatment is tailored to the specific diagnosis.\u003c\/p\u003e\n\u003ch3\u003eCan migraine cause facial pain?\u003c\/h3\u003e\n\u003cp\u003eYes, migraine can spread to the face, and some patients have isolated facial migraine, with attacks fulfilling migraine criteria but located only in the cheek or jaw area. This is often misdiagnosed as sinusitis. Treatment is the same as for migraine.\u003c\/p\u003e\n\u003ch3\u003eWhat is trigeminal neuralgia and how is it different from dental pain?\u003c\/h3\u003e\n\u003cp\u003eTrigeminal neuralgia is a well-defined cranial neuralgia causing severe, sharp facial pain. It is often misdiagnosed as dental pulpitis, leading to unnecessary dental procedures. Unlike dental pain, it is a neurological condition. Diagnosis is based on clinical criteria, and treatment follows established guidelines.\u003c\/p\u003e\n\u003ch3\u003eWhat should I do if I have chronic facial pain and dental treatments haven't helped?\u003c\/h3\u003e\n\u003cp\u003eIf dental causes are excluded and pain persists, consult a neurologist or orofacial pain specialist familiar with ICOP. Keep a pain diary describing pain quality, triggers, and accompanying symptoms. Be cautious about further invasive dental procedures. A second opinion may be helpful if you've been told your pain is psychological.\u003c\/p\u003e\n\u003ch3\u003eWhat is Eagle syndrome and how is it treated?\u003c\/h3\u003e\n\u003cp\u003eEagle syndrome is a rare condition with unilateral neuralgiform pain in the pharynx, tongue, or jaw, triggered by jaw opening, swallowing, or neck rotation. It is caused by an elongated styloid process. Diagnosis is by imaging. Treatment may include surgical removal of the styloid process, or medications like pregabalin, gabapentin, or duloxetine.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal Article:\u003c\/strong\u003e \"Orofacial pain for clinicians: A review of constant and attack-like facial pain syndromes\"\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e Arne May, Rafael Benoliel, Yoshiki Imamura, Maria Pigg, Lene Baad-Hansen, Peter Svensson, and Jan Hoffmann\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eJournal:\u003c\/strong\u003e Cephalalgia, 2023, Vol. 43(8), pages 1–12\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDOI:\u003c\/strong\u003e 10.1177\/03331024231187160\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication Date:\u003c\/strong\u003e Received April 4, 2023; revised May 23, 2023; accepted June 22, 2023\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAffiliations:\u003c\/strong\u003e Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Germany; Rutgers School of Dentistry, New Jersey, USA; Department of Oral Medicine, School of Dentistry, Nihon University Tokyo, Japan; Faculty of Odontology, Malmö University, Sweden; Department of Dentistry and Oral Health, Aarhus University, Denmark; Wolfson Centre for Age-Related Diseases, King's College London, UK; Department of Neurology, King's College London, UK\u003c\/p\u003e\n\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research published in Cephalalgia, the official journal of the International Headache Society. The original article is available under the Creative Commons Attribution-NonCommercial 4.0 License.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47377200808092,"sku":null,"price":0.0,"currency_code":"KRW","in_stock":true}],"url":"https:\/\/diagnosticdetectives.kr\/products\/understanding-orofacial-pain-a-complete-guide-to-constant-and-attack-like-facial-pain-syndromes","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}