Facial pain due to migraine and cluster headache

Persistent idiopathic facial pain

Background

Persistent idiopathic facial pain (PIFP) is a chronic disorder recurring daily for more than two hours per day over more than three months, in the absence of clinical neurological deficit. PIFP is the current terminology for Atypical Facial Pain and is characterized by daily or near daily pain that is initially confined but may subsequently spread. Pain cannot be attributed to any pathological process, although traumatic neuropathic mechanisms are suspected. When present intraorally, PIFP has been termed ‘Atypical Odontalgia’, and this entity is discussed in a separate article in this special issue. PIFP is often a difficult but important differential diagnosis among chronic facial pain syndromes.

Aim

To summarize current knowledge on diagnostic criteria, differential diagnosis, pathophysiology and management of PIFP.

Methods

We present a narrative review reporting current literature and personal experience. Additionally, we discuss and differentiate the common differential diagnoses associated with PIFP including traumatic trigeminal neuropathies, regional myofascial pain, atypical neurovascular pains and atypical trigeminal neuropathic pains.

Results and conclusion

The underlying pathophysiology in PIFP is still enigmatic, however neuropathic mechanisms may be relevant. PIFP needs interdisciplinary collaboration to rule out and manage secondary causes, psychiatric comorbidities and other facial pain syndromes, particularly trigeminal neuralgia. Burden of disease and psychiatric comorbidity screening is recommended at an early stage of disease, and should be addressed in the management plan. Future research is needed to establish clear diagnostic criteria and treatment strategies based on clinical findings and individual pathophysiology.

Prevalence of Facial Pain in Migraine: A Population-Based Study

Unilateral head pain focused on frontal, orbital or parietal regions is a leading symptom of migraine attacks. Rarely, head pain in migraine can extend involving the maxillary or mandibular region of the face, sometimes isolated facial pain is the only and atypical presentation of migraine. The prevalence of these unusual symptoms in migraine is unknown. We aimed to estimate the true prevalence of facial pain in migraine in a population-based sample of 517 migraine patients in Germany. In 46 (8.9%) cases migraine pain involved the head and the lower half of the face. Patients with facial pain suffer more trigemino-autonomic symptoms than migraine patients (47.8% vs. 7.9%; α2 = 66.23, P < 0.001). In one case isolated facial pain without headache was the leading symptom of migraine. Our results demonstrate that facial pain is not unusual in migraine, whereas isolated facial migraine is extremely rare.

Facial migraine in a rhinological setting

This study aims to investigate the incidence of migraine involving the face in a rhinology clinic and to describe its characteristics. It is a study of a cohort of 973 patients consecutively presenting to the outpatient clinic with symptoms of facial pain and/or rhinosinusitis. The study subgroup consisted of patients with facial pain and migraine excluding cluster headache and paroxysmal hemicrania. We studied the features of 51 patients who had facial pain with migraine. The diagnosis was based on the criteria used by the International Headache Society and was also supported by the outcome and response to treatment after a mean of 2 years and 2 months. Of the 973 consecutive patients, 409 (42%) had symptoms of facial pain and/or head pain or pressure. Fifty-one (12%) had migraine. Of these, 39 (76%) had unilateral pain and, in 12 (24%), it was bilateral. The distribution affected the forehead and/or eye or cheek in 32 (63%) patients. Twenty-four (47%) had migraine isolated to the second division of the trigeminal nerve. Twelve per cent of patients attending a rhinology clinic with facial pain had migraine. Of particular interest were the 6% of patients with facial pain who had migraine confined to the second division of the trigeminal nerve. This entity is not widely recognized and has rarely been described in the literature.