Approach Considerations
Medical treatment of persistent idiopathic facial pain (PIFP) is usually less satisfactory than medical treatment of other facial pain syndromes. Pharmacotherapeutic knowledge is paramount in the treatment of this refractory pain syndrome. A multimechanistic approach, using modulation of both ascending and descending pain pathways, is frequently necessary. The goal of therapy is to manage the pain effectively while giving rise to the fewest possible adverse medication effects.
Anticonvulsants (antiepileptic drugs [AEDs]) and antidepressants (eg, tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs], and norepinephrine reuptake inhibitors [NeRIs]) are the mainstays of pharmacologic treatment. Narcotics may be appropriate if administered under careful supervision.
Pharmacologic Therapy
Medications used to treat persistent idiopathic facial pain (PIFP) include the following:
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Antidepressants
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Anticonvulsants
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Substance P depletion agents
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Topical anesthetics
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N -methyl-D-aspartate (NMDA) antagonists
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Tetrahydrocannabinol (THC) or cannabidiol (CBD) receptor agonists
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Opiate medications
Of these classes of medications, anticonvulsants and antidepressants appear to be the most effective. [21] The neuropathic component of the pain responds well to anticonvulsants and antidepressants.
Surgical, Psychiatric, and Alternative Treatments
Details of neurosurgical interventions to treat persistent idiopathic facial pain (PIFP) are beyond the scope of this review. If analgesic surgery is under consideration, it should be performed at a center well versed in such procedures. Occipital nerve block, though useful for treating several craniofacial neuralgias, does not appear to be especially effective against PIFP. [22, 23]
Psychiatric treatment is important in the overall management of a patient with chronic pain.
The results of a small study from Taiwan suggest that low-energy (eg, 800-nm wavelength) diode laser therapy may prove to be a useful alternative treatment for PIFP. [24]
Alternative therapies such as acupuncture and neuromuscular reeducation have been tried and should be considered as part of a comprehensive treatment plan. Available data on alternative treatments are limited. [25, 26]
Consultations
Psychometric testing may be of benefit in the evaluation and treatment of patients with headache and facial pain. Many tests have been applied, but probably the most widely used is the Minnesota Multiple Personality Inventory (MMPI). Although psychometric testing is especially useful in the evaluation of the chronic headache and facial pain patients, a thorough discussion of such testing is beyond the scope of this discussion and is mentioned here only for completeness.
Consultation with a dentist may be of benefit.
All treatments should be provided in cooperation with the patient’s primary care physician.
