General Medical Information

Atypical Facial Pain

Alan G. Finkel
J. Douglas Mann
Thomas F. Lundeen

Atypical facial pain is described as a chronic burning or aching pain without focal findings or any discernible etiology. It is a diagnosis of exclusion. Characteristically the pain is bilateral and changes locations frequently over weeks to months. The pain is not triggered and is not shocklike; thus it is easily distinguishable from trigeminal neuralgia. Pain intensity fluctuates slowly over time, and pain is rarely entirely absent. The pain is typically located in the face and rarely spreads to the cranium, which distinguishes it from tension headache. Palpable muscular spasm involving the pterygoids or masseters is uncommon. Women are much more commonly affected than men and are usually 30 to 50 years old. Significant psychiatric findings are found in 60% to 70% of the patients; depression, somatization, and adjustment disorders are the most common. Psychiatric assessment is recommended.

Atypical facial pain can be managed with antidepressants. Patients are started on a low dose (25 mg) of amitriptyline at bedtime and titrated up until sleep and pain are improved. These patients are at risk for iatrogenic problems due to multiple invasive evaluations and excessive medication.