Facial Neuralgia (Desai) Flashcards
(108 cards)
1
Q
What patient complaint with orofacial pain should always cause concern?
A
Facial numbness
2
Q
What is the most common pain in the dental office?
A
Odontogenic pain secondary to caries, trauma, periodontal pathology
3
Q
What are 7 causes of orofacial pain other than directly dental causes?
A
- Musculoskeletal (e.g. TMD)
- Neuralgia
- Neuropathic
- Vascular
- Neoplastic
- Infectious (bacterial, fungal, viral)
- Burning Mouth Syndrome (can be psychological, vitamin deficiency, parafunction, neuropathy)
4
Q
What percent of the population calling pain from sinusitis is a chronic problem? (not even sure what this question is asking)
A
15%
5
Q
How to differentiate sinusitis from other orofacial pain, when teeth experiencing referred pain from sinusitis will be temperature sensitive and percussion sensitive?
A
Will be a whole quadrant vs only one tooth
6
Q
What is an autoimmune disease that can cause salivary gland enlargement?
A
Sjogren’s syndrome
7
Q
What is the average time it takes to find an effective treatment for headaches?
A
3.5 years
8
Q
What is the classification of headaches by the International Headache Society?
A
- Primary
- Secondary
- Cranial neuralgias
9
Q
Are migraines primary or secondary headaches?
A
Primary
10
Q
What are the 2 major types of migraine and which is the most common?
A
- Migraine with Aura
- Migraine without Aura
(The migraine without aura is the most common)
11
Q
What is the duration of a migraine?
A
4-72 hours
12
Q
What is the location of a migraine?
A
Always unilateral
13
Q
What are the characteristics of a migraine (must have at least two)?
A
- Unilateral
- Pulsating
- Moderate to severe pain intensity (5-10 out of 10)
- Aggravation by or causing avoidance of routine physical activity
14
Q
At least one of what 4 things will accompany a migraine?
A
- Nausea (90%)
- Vomiting (35%)
- Photophobia
- Phonophobia
15
Q
What percentage of migraines have a prodrome that is difficult to describe?
A
60%
16
Q
What percentage of migraines have auras?
A
20%
17
Q
What is the character of a migraine aura?
A
Develop over 5-20 minutes and last less than 30 minutes
18
Q
40% of migraines start how and progress to what?
A
Begin as the whole head, moderate intensity, go to pulsating unilateral above the eyes
19
Q
What percentage of migraines have identifiable triggers that can be avoided as a means to treat the migraines?
A
10%
20
Q
What are the 2 most common triptans prescribed for migraines?
A
- Sumatriptan
2. Maxalt
21
Q
What is the sumatriptan mechanism of action?
A
Selective agonist for serotonin in cranial arteries causes vasoconstriction and reduces neurogenic inflammation associated with antidromic neuronal transmission correlation with relief of migraine
22
Q
What is ergotamine?
A
A vasoconstrictor of cranial blood vessels and is also a uterine stimulant.
23
Q
What are the most common prophylactic medications for migraines?
A
- Antihypertensives
- Calcium channel blockers
- Beta blockers
24
Q
What is a headache that is not associated with muscle tension or stress leading to abnormal central pain modulation leads to hyperalgesia (think being sore after working out and then a light touch hurts)
A
Tension-type Headache (TTH)
25
What is the difference in location between a tension type headache (TTH) and a migraine?
TTH is bilateral
26
What is the difference in pain between a TTH and a migraine?
TTH does not pulsate (but a migraine DOES pulsate)
27
What is the difference in aggravation of symptoms between a TTH and migraine?
TTH not aggravated by routine physical activity.
| Migraine is aggravated by routine physical activity
28
What is the occurrence of TTH?
At least 10 episodes occurring on fewer than 1 day per month (<12 days/yr)
29
What is the duration of tension-type headaches?
30 minutes to 7 days
30
Will TTH have nausea or vomiting like a migraine?
No
31
Can TTH have photophobia like a migraine?
Yes but not a lot
32
What is a headache that is unilateral above the eye, lasting 4-72 hours?
Migraine
33
What is a headache that is bilateral band of pressure around the head lasting anywhere from 30 minutes to 7 days?
Tension Type Headache
34
Should TTH be treated with frequent OTC analgesic or barbiturate combinations and why?
No. Avoid developing chronic TTH or chronic daily headache.
35
What is the treatment for TTH?
Stress management, corrected posture, stretching, physical therapy, pharmacologic
36
What is a form of cell-mediated immune reaction causing vasculitis of blood vessels in the head and neck region?
Temporal arteritis
37
What is the common vessel causing temporal arteritis?
Temporal artery
38
What can Temporal Arteritis be closely related to?
Polymyalgia Rheumatica (inflammatory disorder involving pain and stiffness in shoulder and hips)
39
What is a potential risk of Temporal Arteritis?
Sudden blindness caused by diminished blood supply due to artery inflammation
40
What is the character of Temporal Arteritis headache?
Usually unilateral or occasionally (rarely) bilateral continuous throbbing intense headache directly at the temple. Tenderness to mild touching (even brushing your hair)
41
What are 2 complaints that might lead to thinking the patient has Temporal Arteritis?
1. Jaw claudication (pain on chewing)
| 2. Tender scalp when brushing
42
What are 2 inflammatory markers that can be used to aide in Temporal Arteritis diagnosis?
1. Erythrocyte Sedimentation Rate (ESR)
2. C-reactive protein (CRP)
(these are both non-specific markers)
43
What gives the most conclusive diagnosis for Temporal Arteritis?
Biopsy temporal artery
44
What is the drug of choice for Temporal Arteritis treatment?
High dose corticosteroid (refer to neurologist / neurosurgeon)
45
What is a group of syndromes incorporating short unilateral headache attacks along with cranial autonomic symptoms along the autonomic side including ocular pain, lacrimation, eyelid edema, rhinorrhea, ptosis and mitosis (all of which are autonomic signs)?
Trigeminal Autonomic Cephalgias (TACs)
46
The symptoms of Trigeminal Autonomic Cephalgias (TACs) normally occur along what division of the trigeminal nerve?
First Division (V1)
47
What are 3 types of trigeminal autonomic cephalgias (TACs)?
1. Cluster headache (CH)
2. Paroxysmal Hemicrania (PH)
3. Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)
48
What is the term for severe or very severe unilateral orbital supraorbital and/or temporal pain lasting 15-180 mins if untreated?
Cluster Headaches
49
Cluster headaches show what autonomic response in 80% of cases?
Nasal congestion and / or rhinorrhea
50
What is the frequency of cluster headaches?
One every other day to 8 per day
51
What is the demographic for cluster headaches?
30 year old males
52
What are 6 preventive meds for cluster headache treatment?
1. Verapamil (Calcium channel blocker)
2. Prednisone (Corticosteroid)
3. Methysergide
4. Lithium
5. Valproate (increase GABA (inhibitory neurotransmitter))
6. Gabapentin (GABA analogue)
53
What are 4 abortive treatments to be used at the onset of Cluster Headache symptoms?
1. Triptans
2. Ergotamine
3. Oxygen
4. Intranasal Topical Lidocaine
54
What is the term for severe, shorter lasting unilateral pain localized to periorbital and temporal sites and ipsilateral autonomic signs as seen in Cluster headaches?
Paroxysmal hemicrania
55
What is the drug that paroxysmal hemicrania is responsive to?
Indomethacin
56
Will any of the other TACs (Cluster Headaches, SUNCT) respond to Indomethacin?
No, only Paroxysmal Hemicrania
57
What is the demographic for Paroxysmal Hemicrania?
Females 20-30 years old
58
What are the 5 preventative meds for Paroxysmal Hemicrania?
1. Verapamil
2. NSAIDs
3. Prednisone
4. Triptans
5. Acetazolamide (inhibits carbonic anhydrase)
59
What is an abortive treatment for Paroxysmal Hemicrania, to be taken at onset of symptoms?
Indomethacin (NSAID, COX1 and 2 inhibitor)
60
What is the term for bursts of moderate to severe burning , piercing, or throbbing pain around the eye or temple?
SUNCT
61
SUNCT will peak within how long of onset of symptoms and when will it normally occur?
1. Peaks within seconds of onset (5 seconds to 4 minutes)
2. Occurs in daytime
3. 5-6 attacks / hour
62
Will standard therapies for short term headaches work for SUNCT?
No
63
What are 3 medicines for SUNCT treatment?
1. Gabapentine
2. Lamotrigine (anticonvulsant)
3. Carbamazepine (anticonvulsant)
64
What is the surgical intervention for SUNCT?
Glycerol injection of trigeminal nerve?
65
What is the most common non-headache facial pain?
Trigeminal neuralgia
66
Is trigeminal neuralgia a specific disease or is it any neuralgia involving the trigeminal nerve?
Specific disease
67
What is the definition of paroxysmal?
A sudden attack or violent expression of a particular emotion or activity; a sudden recurrence or worsening of symptoms
68
What is the term for paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting one or more divisions of the trigeminal nerve and with refractory periods between attacks as well as being precipitated from trigger areas?
Trigeminal Neuralgia
69
What is the character of pain of Trigeminal Neuralgia?
Intense, sharp, superficial, stabbing
70
What will precipitate a trigeminal neuralgia?
Trigger point
71
Is trigeminal neuralgia unilateral or bilateral?
Unilateral, slightly more on left than right
72
What division of the trigeminal is commonly affected by trigeminal neuralgia?
2nd and 3rd division (less than 5 percent have the 1st division affected)
73
What is the Tic Douloureus of Trigeminal Neuralgia?
Spasm of the face on the affected side caused by pain
74
What is the primary hypothesis of Trigeminal Neuralgia?
Compression of trigeminal root by tortuous or aberrant vessels which can lead to demyelination of nerve fibers
75
What are the secondary etiologies of Trigeminal Neuralgia?
Rarely central tumors such as meningioma.
| Central demyelination as with multiple sclerosis
76
What is always indicated when the diagnosis is trigeminal neuralgia?
MRI to rule out a tumor or demyelination disease
77
What is the medicine with the best evidence for success with treatment of Trigeminal Neuralgia?
Carbamazepine (Tegretol / Trileptal)
78
What is the risk with treating trigeminal neuralgia with Carbamazepine?
Can cause bone marrow suppression and liver problems
79
What are 2 other treatments for trigeminal neuralgia, both with decreased efficacy when compared to Carbamazepine?
1. Phenytoin (Dilantin)
| 2. Gabapentin (Neurotonin)
80
Of Carbamazepine, Phenytoin, and Gabapentin, which drug requires little monitoring when treating Trigeminal Neuralgia
Gabapentin
81
What are 3 peripheral therapies for Trigeminal Neuralgia?
1. Radiofrequency thermocoagulation
2. Glycerol rhizotomy (destroy nerve roots)
3. Cryotherapy
82
What is the gamma knife surgery for Trigeminal Neuralgia therapy?
Pulsation of specific radio frequencies at the nerve root using radioactive pellets
83
What are the radioactive pellets used in Gamma Knife surgery and their half-life?
Cobalt 60
| Half-life of 5 years
84
What is the term for paroxysmal attacks of facial pain lasting from a fraction of a second to 2 minutes, unilaterally within the posterior part of the tongue, tonsillar fossa, pharynx or beneath angle of the lower jaw and or ear?
Glossopharyngeal Neuralgia (similar to trigeminal neuralgia but distribution is different)
85
What is the character of glossopharyngeal neuralgia?
Sharp, stabbing, severe (for about 40 seconds 7 times a day)
86
What are triggers for glossopharyngeal neuralgia?
Swallow, chew, talk, cough, yawn
87
What syndrome should be included when considering a differentiation with glossopharyngeal neuralgia?
Eagle syndrome
88
What is the difference between complex regional pain syndrome I and II (CRPS I and CRPS II)?
CRPS I has no demonstrable nerve injury
89
Reflex sympathetic dystrophy is associated with which complex regional pain syndrome?
Complex Regional Pain Syndrome I
90
Causalgia is associated with which complex regional pain syndrome?
Complex Regional Pain Syndrome II
91
How is a diagnosis of Complex Regional Pain Syndrome (CRPS) reached?
By ENT or rheumatologist by exclusion. Will have spontaneous pain or hyperalgesia or hyperesthesia not limited to single nerve territory
92
What is the term for persistent facial pain that does not have the characteristics of the cranial neuralgias and is not attributed to another disorder, will have deep poorly localized pain that seems to be migrating, lasts 6+ hours a day every single day for three months?
Persistent Idiopathic Facial Pain
93
Persistent Idiopathic facial pain / atypical odontalgia / atypical facial pain has what probable etiology?
Deafferentiation (pain is present even when stimulus is removed)
94
If the patient has persistent idiopathic facial pain, what would be their response to local anesthesia if you want to see if it is idiopathic or caused by a tooth?
If anesthesia takes pain away, it is a tooth problem. If anesthesia does not relieve pain, it is idiopathic
95
Is referred pain the same as phantom / deafferentation pain?
No
96
What is the term for continuous burning pain of the oral mucosa in the absence of local or systemic pathology?
Burning Mouth Syndrome
97
What is the first line therapy for Burning Mouth Syndrome?
Clonazepam (Benzodiazepine wafer)
98
Are sialologues such as pilocarpine or Cevimeline accepted treatments for Burning mouth syndrome?
No because it is not a salivation problem
99
How can you get pain above the neck?
1. Toothaches
2. TMD
3. Headache / migraines
4. Trigeminal neuralgia
5. Atypical facial pain
6. Burning mouth syndrome
100
What types of salivary gland pathology can cause pain?
1. Stones
| 2. Tumors
101
True or false: most migraine sufferers self-diagnose.
True
102
What are some common prophylactic treatments for migraines?
1. Calcium channel blockers or Beta blockers
2. Antidepressants
3. Serotonin antagonists
4. Antoiconvulsants
5. Others
103
A patient under 40 with trigeminal neuralgia often has what?
Multiple sclerosis.
104
What should you always acquire when you suspect trigeminal neuralgia?
MRI of the brain
105
What may be the main cause of CRPS?
Noxious event (pretty much know everything on the CRPS diagnosis slide)
106
What question will he likely ask us regarding atypical facial pain?
"Anesthesia does not get rid of the pain, what is the diagnosis?"
107
A patient in their 40s with symptoms similar to trigeminal neuralgia, what is the diagnosis?
Multiple sclerosis
108
Numbness of the face that cannot be attributed to a tumor should be diagnosed as what?
Multiple sclerosis
