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Facial Pain Syndromes Affected by High Disease Burden, Inconsistent Treatment Effectiveness

The primary pharmaceutical options suggested by national guidelines were considered effective by only 13.8% and 14.9% of the patients with persistent idiopathic facial pain.

A longitudinal, 10-year study evaluating common nondental facial pain syndromes highlighted the considerable disease burden faced by patients with these conditions, especially those with persistent idiopathic facial pain (PIFP) and neuropathic facial pain (NEUROP), who struggled to find success even when on therapies suggested by guidelines.

Senior author Arne May, MD, PhD, professor of neurology, Department of Systems Neuroscience University of Hamburg, and colleagues aimed to prospectively characterize and compare the clinical key features and development of the 3 most common facial pain syndromes encountered in a tertiary facial pain and headache care center. A total of 411 data sets of patients with chronic facial pain were compiled, 150 of which had PIFP, 111 with trigeminal neuralgia (TN), and 86 with NEUROP.

After each consultation and evaluation of the previous treatment, clinicians rated each patient on whether the therapy was initiated according to the German guidelines, as well as whether the patient had exploited all available means of conventional therapy. For 56.7% of the patients with PIFP, the previous therapy followed the national guideline, and only 1.3% of patients had strategies as outlined by the national guideline and were considered medically intractable. Treatment with guideline therapy was followed for 75.7% of TN cases and 66.3% of those with NEUROP.

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Most patients in the study had tried at least 1 preventive medication. Tricyclic antidepressants and calcium channel blocks, treatments recommended by national guidelines for patients with PIFP, had low efficacy rates of 13.5% and 30% for this patient population, respectively. Most patients (84.7%) with TN tried a preventive medication and demonstrated comparatively higher efficacy rates of the most commonly used medication classes, sodium (65.2%) and calcium channel blockers (50.9%).

In 83% of the patients with PIFP, 54.8% of the patients with TN, and 44.2% of the patients with NEUROP, dental interventions had been performed to reduce the pain. Dental extraction, root canal treatment, and apicoectomy, were the 3 commonly reported procedures, in that order, for all 3 of the syndromes evaluated. Notably, 99.3% of the patients with PIFP had primarily consulted a dentist due to their pain syndrome.

Within the last 12 months of the study, patients with PIFP reported a median of 10 medical consultations due to their facial pain (first quartile: 5, third quartile: 20), similar to those with NEUROP (median: 10; first quartile: 4; third quartile: 20). Those with TN reported a median of 5 (first quartile: 3; third quartile: 10). General practitioners, neurologists, and in the cases of PIFP and NEUROP, also otolaryngologists, had been seen by more than half of the patients.

In a subgroup of patients with PIFP, investigators evaluated whether pain interfered with their sleep, for which 70.2% (66 of 94) said this was not the case. Additionally, 48.9% of these patients experienced no pain when waking up, and only 27.7% of the patients started to feel pain within the first 30 minutes after waking up. As for the other groups, 58.1% of patients with TN experienced nightly attacks, and 46.5% of patients with NEUROP experienced pain also at night and reported to be woken up by it.

As for quality of life, data from the Patient Health Questionnaire (PHQ-D) showed that only 34.1% (n = 140) of the patients did not report depressive symptoms, and that 6.1% (n = 25) had signs of major depression.

Paul Mathew, MD, DNBPAS, FAAN, FAHS, assistant professor of neurology, Harvard Medical School, has been a leader in studying pain syndromes, including cranial neuralgias. Listen to his commentary below, as he outlines the related areas of research regarding cranial neuralgias and the optimal time to proceed with surgery.

REFERENCE
Ziegeler C, Brauns G, May A. Characteristics and natural disease history of persistent idiopathic facial pain, trigeminal neuralgia, and neuropathic facial pain. Headache. Published online October 7, 2021. doi:10.1111/head.14212