Oro-facial pain

These conditions should be initially assessed by Neurologist, dentist or other to exclude important underlying conditions before referral to PPMS.

Oro-facial pain coniditions include:

• Trigeminal neuralgia
  • Chronic pain affecting the distribution of the 5th cranial nerve
  • Pain can be intermittent (TN1) or continuous (TN2)
  • May be caused by pressure on the nerve of a blood vessel or rarely tumour or previous trauma
• Post herpetic neuralgia
  • Persistent pain after herpes zoster infection
  • More common in elderly and affecting the face
• Atypical facial pain
  • A pain disorder of the face, is often compared to trigeminal neuralgia but is a different entity. Symptoms are more persistent, with few, if any, periods of remission. Pain is usually localized to one side of the face and can be described as sharp, dull, crushing, aching, burning, pulling or squeezing. There are many possible causes of ATFP, and diagnosis is usually reached through a process of elimination
• Chronic temporomandibular pain
  • More common in chronic widespread pain syndrome and chronic fatigue syndromes
• Glossopharyngeal neuralgia
  • Repeated severe episodes of pain involving the tongue, throat, ear and tonsils
  • May be caused by pressure from blood vessels, tumour, infections but often no cause is found

Other important information for referring practitioners

Lifestyle changes

• Encourage healthy activity within pain limits
  • Consider physio referral
  • Desensitisation massage
  • Hydrotherapy
• Ensure adequate sleep
• Check for mood disturbances and relationship difficulties
  • Consider psychology referral for any mood disturbances and to assist with pain control

Medical management

• Optimise medical management of predisposing secondary condition (if present)
• Set realistic goals
• Treat associated mood disorders
• Avoid over-reliance of medication, encourage self-management and set realistic goals for treatment
  • Consider nerve blocking procedure if single nerve involvement
  • Transcutaneous electrical nerve stimulation (TENS)
  • If trialling medication, start at low dose and titrate upwards
  • Agree on trial period for medication

Current medications used in chronic oro-facial pain are:

• Amitriptyline:
  • start at 10mg and slowly escalate dose (this may take weeks)
  • max dose 75-100mg
  • consider nortriptyline in older patients
  • anti-cholinergic effects on bladder can be troublesome in elderly males
• Pregabalin:
  • PBS restricted for neuropathic pain refractory to treatment with other drugs
• Carbamazepine (used primarily for trigeminal neuralgia and post herpetic neuralgia)
• Duloxetine:
  • PBS approved for neuropathic pain and major depressive disorder
• Consider topical 5% lignocaine patch for post herpetic neuralgia

Try to avoid opioid medications. Only use an opioid for exacerbations and set time limits on prescribing.

Referral requirements

A referral may be rejected without the following information.