Painful Cranial Neuropathies and other Facial Pain

Abstract

Head pain is caused by activation of the trigeminocervical complex, which is common final pathway for all headaches. Due to the overlapping innervation of the trigeminal nerve and the terminal branches of the first cervical nerves, the innervation area of the trigeminocervical complex covers the entire head. In response to various, endogenous or exogenous, potential or real causes of damage, activation of the trigeminocervical complex can also trigger vegetative and vasomotor reactions. Irradiation of pain to adjacent regions of the head and face reduces the localization significance of pain, which represents a significant differential diagnostic difficulty. It is known that the following structures of the head are sensitive to pain: skin, subcutaneous tissue, muscles, arteries, periosteum, structures of the eye, ear and nasal cavities, intracranial venous sinuses, parts of the dura mater at the base of the brain, arteries in the dura and soft meninges and cranial nerves (nn.V, IX, X and nn. cervicales). On the other hand, the bones of the skull, most of the dura and soft meninges, the brain parenchyma, the ependyma of the ventricles and the choroid plexus do not represent pain-sensitive structures.

Analysis and interpretation of data obtained from a structured clinical interview, and clinical and neurological examination of the patient is usually sufficient to establish an accurate diagnosis. Although the diagnosis of head pain syndromes is most often clinical, in some conditions additional diagnostics are necessary. When examining the patient and during the clinical interview, special attention should be paid to data related to the pain syndrome itself, such as pain localization, lateralization, frequency and duration of pain, intensity and character of pain, the presence of associated symptoms, the presence of precipitating and relaxing factors, the degree of disability during and after the attack, the presence of complaints before the painful attack itself, the sensitivity of pain to the applied pain therapy, etc.

Data from personal health history and family history are especially important. Clinically, it is significant that chronic pain syndromes of the head and face arise from the transformation of primary, recurrent episodic syndromes.

Timely diagnosis and therapeutic treatment of episodic conditions is important for preventing their chronicity. At the end of the clinical evaluation of a patient with a painful syndrome of the head and face, it is necessary to consider whether the presented clinical condition is a consequence of some other pathological process; what is its clinical course so far (episodic - rare/frequent attacks or chronic course); whether additional diagnostics are necessary and which diagnostic procedure should be performed; which therapy is optimal for an acute approach, whether and with which therapy preventive intervention should be used, etc.

• Data from personal health history and family history are especially important. Clinically, it is significant that chronic pain syndromes of the head and face arise from the transformation of primary, recurrent episodic syndromes.
• Timely diagnosis and therapeutic treatment of episodic conditions is important for preventing their chronicity.
• Given that the chronicity/transformation of this pain conditions result over medication their clinical knowledge is crucial.