Multidisciplinary Approach Needed for the Diagnosis of Complex Orofacial Pain

Artwork illustrating trigeminal neuralgia, showing nerves (yellow) and muscle (red) in a woman’s face. Trigeminal neuralgia (also called tic douloureux) is a severe burning or stabbing pain that affects the branches of the trigeminal nerve, the fifth and largest of the cranial nerves. The trigeminal nerve is split into three divisions: theophthalmic (eyes), maxillary (facial) and mandibular (jaw) nerves. Branches of the maxillary nerve to the cheek are the main features in this illustration.
The range of causes underlying complex orofacial pain highlights the importance of taking a multidisciplinary approach for the diagnosis of these conditions.

The range of causes underlying complex orofacial pain highlights the importance of taking a multidisciplinary approach for the diagnosis of these conditions to reduce unnecessary procedures or diagnostic delays, according to a study published in the Journal of Headache and Pain.

In this study, 142 patients (70% women; mean age, 51±3) presenting to a tertiary multidisciplinary orofacial pain clinic between January 2015 and January 2018 were included. Dental causes for orofacial pain were excluded using a clinical audit of initial consultation clinic letters and subsequent follow-up reviews.

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In this cohort, the most common orofacial pain diagnoses were painful post-traumatic trigeminal neuropathy (n=17; 12%), migraine (n=38; 27%), and possible trigeminal autonomic cephalalgias (n=62; 44%). The most common trigeminal autonomic cephalalgias diagnosis was hemicrania continua (n=13;   9%), a higher prevalence than that reported in headache and neurology clinics. The condition most commonly misdiagnosed was trigeminal neuralgia (5 of 6 patients). Time to diagnosis was 5.6 years compared with 7 years in patients with a confirmed trigeminal autonomic cephalalgia. For patients with hemicrania continua, time to diagnosis was 8.7 years. Dental procedures were common in patients with trigeminal autonomic cephalalgia.

 “[Trigeminal autonomic cephalalgias] are an important group of primary headache disorders dentists and oral surgeons should be aware of, as many patients with unilateral side-locked primary headaches present to the dental services. Neurologists should be [cognizant] of this presentation pattern when seeing patients from these pathways. [Hemicrania continua] is underdiagnosed and this may be due to the presentation to other specialties rather than to neurology and headache services. We have found the most effective way to ensure patients are diagnosed correctly and managed optimally is a multi-disciplinary service with dentists, oral surgeons, and headache specialists,” noted the study authors.


Wei DY, Moreno-Ajona D, Renton T, Goadsby PJ. Trigeminal autonomic cephalalgias presenting in a multidisciplinary tertiary orofacial pain clinic. J Headache Pain. 2019 Jun 11;20(1):69.

This article originally appeared on Clinical Pain Advisor