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Suggest Treatment For Nerve Pain In Face
Question: I'm calling on behalf of a friend in Creston BC. She has nerve pain on her face which began on one side, and is now spreading to the other side. Her doctor sent her for an x ray then a cat scan of sinuses only, both of which came back negative, then referred her to a neurologist. She has been waiting a week without yet getting an appointment, though she has called back her doctor once to try to speed the process. She is reluctant to go to an emergency room because she fears being too demanding, feels she should be satisfied with the regular procedures even though they are slow. She and I both fear this is a brain tumor which seems to be developing quickly. What should she do?
Brief Answer:
Brain tumor not likely.
Detailed Answer:
I read your question carefully and I appreciate your concern about your friend.
However you shouldn't be rushing towards a brain tumor diagnosis as apart from having other symptoms, it is very unlikely to manifest itself with pain in the face and it wouldn't be bilateral.
It would be helpful to know a little more about this pain such as:
-distribution in the face
-characteristics - sharp, stabbing, electric shock like, dull, throbbing etc
-duration of the episodes (seconds, minutes, hours, days)
-frequency (how many times a hour/day/week)
-exacerbating factors (eating, speaking, touching)
-accompanying signs (lacrimation, eye or nasal congestion, vomiting, fever)
Some more info might help in making a more precise recommendation.
From the info you give, since sinusitis has been excluded, I would look first into conditions like temporomandibular joint dysfunction (the joint between the lower jaw and the skull).
A nerve related cause could be trigeminal neuralgia, but it is very rarely bilateral.
I remain at your disposal for further questions.
Brain tumor not likely.
Detailed Answer:
I read your question carefully and I appreciate your concern about your friend.
However you shouldn't be rushing towards a brain tumor diagnosis as apart from having other symptoms, it is very unlikely to manifest itself with pain in the face and it wouldn't be bilateral.
It would be helpful to know a little more about this pain such as:
-distribution in the face
-characteristics - sharp, stabbing, electric shock like, dull, throbbing etc
-duration of the episodes (seconds, minutes, hours, days)
-frequency (how many times a hour/day/week)
-exacerbating factors (eating, speaking, touching)
-accompanying signs (lacrimation, eye or nasal congestion, vomiting, fever)
Some more info might help in making a more precise recommendation.
From the info you give, since sinusitis has been excluded, I would look first into conditions like temporomandibular joint dysfunction (the joint between the lower jaw and the skull).
A nerve related cause could be trigeminal neuralgia, but it is very rarely bilateral.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you Dr Taka.
My friend has supplied the following further information in response to your reply. Please give us your further recommendations:
I don't have pain in my face, it's more like the sensation of having Novocaine leaving my face after freezing - truly a paresthesia. It's exactly the V2 branch of CN5 in the immediate maxillary region. My gums (upper), lip (upper), roof of my mouth, philtrum/above my lips, nostrils, and into the cheek area are the region right now. It's just always there (whether or not I touch it) though sometimes it's more active (if that's the right word) than others. It doesn't come and go in bursts; it's really persistent. The right side continued for about a month, never totally resolving. I had about a week of both sides being very persistent and now the right side is much less so, with the left much more.
There has been nothing I can see that exacerbates it. At times it will feel like burning - sunburn or the sensation when you have capsicum on your fingers and rub your eyes but I can't figure out why it changes sometimes. Largely it's that almost numb feeling but it isn't ever numb - I can feel heat, etc. It is very sensitive to temperature though. It gets uncomfortable especially in the cold. The numb feeling is less severe or more severe at times but I can't determine a reason for that. It does cause me to wake at night if something touches my face. If I touch the area with my fingers or a blanket does, it feels intensely like an ice cube or freezing but again, without being truly numb.
The onset was on the right side - lip, philtrum, cheek, nostril. About a month after the symptoms on my right side started, I woke up with the symptoms spread to my gums, palate, and left side. The left side is persisting now with the right much less.
I'm trying to think of anything else that could be slightly useful to know.
I have recently started having motion sickness, and having 'woozy' periods where I am not truly dizzy just woozy, if that makes sense. Up until November I could read in the car without any problem but now even a bit of reading or knitting makes me green.
I have had dental pain that has been unexplained for about a year. My dentist has tried to resolve it but without success and without any reason indicated in investigation. Over the last few months I have had to joke with my staff about my leaky eyes. I assumed a lot of this was sinus related so I didn't think much of it. Finding out that my sinuses are clear has been almost disappointing.
I also wonder if the right shoulder pain I have had is somehow related though I don't know how it could be. This summer I had completely unexplained shoulder pain with a clicking sound that has been less severe with careful use but was pretty bad up until around November.
I have also had on going facial/neck flushing for a year (or maybe longer) at least that also seem inexplicable. It's not a rash, more like my friends describe "hot flashes" but it's not perimenopause. It was chalked up to a strange side effect of Crohn's.
I have also got a long history of intermittent arthritis like sx in my right hip that were chalked up to Crohn's.
My friend has supplied the following further information in response to your reply. Please give us your further recommendations:
I don't have pain in my face, it's more like the sensation of having Novocaine leaving my face after freezing - truly a paresthesia. It's exactly the V2 branch of CN5 in the immediate maxillary region. My gums (upper), lip (upper), roof of my mouth, philtrum/above my lips, nostrils, and into the cheek area are the region right now. It's just always there (whether or not I touch it) though sometimes it's more active (if that's the right word) than others. It doesn't come and go in bursts; it's really persistent. The right side continued for about a month, never totally resolving. I had about a week of both sides being very persistent and now the right side is much less so, with the left much more.
There has been nothing I can see that exacerbates it. At times it will feel like burning - sunburn or the sensation when you have capsicum on your fingers and rub your eyes but I can't figure out why it changes sometimes. Largely it's that almost numb feeling but it isn't ever numb - I can feel heat, etc. It is very sensitive to temperature though. It gets uncomfortable especially in the cold. The numb feeling is less severe or more severe at times but I can't determine a reason for that. It does cause me to wake at night if something touches my face. If I touch the area with my fingers or a blanket does, it feels intensely like an ice cube or freezing but again, without being truly numb.
The onset was on the right side - lip, philtrum, cheek, nostril. About a month after the symptoms on my right side started, I woke up with the symptoms spread to my gums, palate, and left side. The left side is persisting now with the right much less.
I'm trying to think of anything else that could be slightly useful to know.
I have recently started having motion sickness, and having 'woozy' periods where I am not truly dizzy just woozy, if that makes sense. Up until November I could read in the car without any problem but now even a bit of reading or knitting makes me green.
I have had dental pain that has been unexplained for about a year. My dentist has tried to resolve it but without success and without any reason indicated in investigation. Over the last few months I have had to joke with my staff about my leaky eyes. I assumed a lot of this was sinus related so I didn't think much of it. Finding out that my sinuses are clear has been almost disappointing.
I also wonder if the right shoulder pain I have had is somehow related though I don't know how it could be. This summer I had completely unexplained shoulder pain with a clicking sound that has been less severe with careful use but was pretty bad up until around November.
I have also had on going facial/neck flushing for a year (or maybe longer) at least that also seem inexplicable. It's not a rash, more like my friends describe "hot flashes" but it's not perimenopause. It was chalked up to a strange side effect of Crohn's.
I have also got a long history of intermittent arthritis like sx in my right hip that were chalked up to Crohn's.
Brief Answer:
Trigeminal neuropathy or idiopathic persistent facial pain more likely.
Detailed Answer:
Thank you for providing such detailed info. Head and facial pain can be of many kinds and that description serves to exclude many causes.
From what I read it looks like a case of trigeminal neuropathy. It is an affection of the trigeminal nerve not to be confused with trigeminal neuralgia which causes short stabbing pain.
The causes can be many, but the history and the fact it is bilateral renders not likely (thankfully) local processes like brain tumor, stroke, infections (although MRI should be considered). Also dental causes seem to have been excluded.
The most probable cause is autoimmune involvement in the setting of a history for autoimmune condition like Chron's disease or also idiopathic trigeminal neuropathy (idiopathic meaning no cause can be found).
Other possible causes might be temporomandibular dysfunction (which I mentioned before, but after knowing more consider less likely) and persistent idiopathic facial pain.
As you see idiopathic trigeminal neuropathy and idiopathic facial pain are diagnosis of exclusion, so before reaching to a conclusion an MRI exam is indicated to exclude other possible causes like those I mentioned above or multiple sclerosis, sarcoidosis, nasopharyngeal tumor etc. I am confident it will most probably come back normal but it is necessary.
I don't believe the shoulder or the flashing symptoms are related.
As for treatment if over the counter medication like Ibuprofen doesn't work treatment with anticonvulsant drugs like Pregabalin, Gabapentin or antidepressants like Amitriptyline can be considered.
Trigeminal neuropathy or idiopathic persistent facial pain more likely.
Detailed Answer:
Thank you for providing such detailed info. Head and facial pain can be of many kinds and that description serves to exclude many causes.
From what I read it looks like a case of trigeminal neuropathy. It is an affection of the trigeminal nerve not to be confused with trigeminal neuralgia which causes short stabbing pain.
The causes can be many, but the history and the fact it is bilateral renders not likely (thankfully) local processes like brain tumor, stroke, infections (although MRI should be considered). Also dental causes seem to have been excluded.
The most probable cause is autoimmune involvement in the setting of a history for autoimmune condition like Chron's disease or also idiopathic trigeminal neuropathy (idiopathic meaning no cause can be found).
Other possible causes might be temporomandibular dysfunction (which I mentioned before, but after knowing more consider less likely) and persistent idiopathic facial pain.
As you see idiopathic trigeminal neuropathy and idiopathic facial pain are diagnosis of exclusion, so before reaching to a conclusion an MRI exam is indicated to exclude other possible causes like those I mentioned above or multiple sclerosis, sarcoidosis, nasopharyngeal tumor etc. I am confident it will most probably come back normal but it is necessary.
I don't believe the shoulder or the flashing symptoms are related.
As for treatment if over the counter medication like Ibuprofen doesn't work treatment with anticonvulsant drugs like Pregabalin, Gabapentin or antidepressants like Amitriptyline can be considered.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you Dr Taka for your generous help,
my friend has these final questions:
Advil definitely doesn't help but if it's not likely to be anything worse than this, I can certainly manage.
The doctor I saw about the flushing and joint pain suspects I have some rare syndrome that's a bigger autoimmune constellation. She didn't know of one but she said things just seem too connected to be random autoimmune things. I suspect this is one more piece of the puzzle?
I think the only thing I would appreciate knowing is what else I could try for symptom relief. To date I have OTC NSAIDs, and massage. I would not prefer something stronger (like T3) and would rather manage as it's annoying and not painful. Would he recommend anything else? I will be trying acupuncture as well because, at this point, why not?
I am wondering too if this is something degenerative?
my friend has these final questions:
Advil definitely doesn't help but if it's not likely to be anything worse than this, I can certainly manage.
The doctor I saw about the flushing and joint pain suspects I have some rare syndrome that's a bigger autoimmune constellation. She didn't know of one but she said things just seem too connected to be random autoimmune things. I suspect this is one more piece of the puzzle?
I think the only thing I would appreciate knowing is what else I could try for symptom relief. To date I have OTC NSAIDs, and massage. I would not prefer something stronger (like T3) and would rather manage as it's annoying and not painful. Would he recommend anything else? I will be trying acupuncture as well because, at this point, why not?
I am wondering too if this is something degenerative?
Brief Answer:
Read below
Detailed Answer:
It seems the opinion of her doctor and mine are similar, considering I gave either an idiopathic involvement or an autoimmune one of the trigeminal nerve as the most probable one.
I am not sure what do you mean by T3 medication. If it's simply annoying and bearable abstinence from more treatment can be considered, as she said it has subsided on the one side already. If a medication was to be tried as I said Amitriptyline or Pregabalin used for neuropathic symptoms can be tried.
I don't think it's a neurological degenerative disease if that is what you mean, it is not the clinical presentation of those conditions.
I hope things work oit for the best.
Read below
Detailed Answer:
It seems the opinion of her doctor and mine are similar, considering I gave either an idiopathic involvement or an autoimmune one of the trigeminal nerve as the most probable one.
I am not sure what do you mean by T3 medication. If it's simply annoying and bearable abstinence from more treatment can be considered, as she said it has subsided on the one side already. If a medication was to be tried as I said Amitriptyline or Pregabalin used for neuropathic symptoms can be tried.
I don't think it's a neurological degenerative disease if that is what you mean, it is not the clinical presentation of those conditions.
I hope things work oit for the best.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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