Rafael Benoliel

Summary points 1. Trigeminal autonomic cephalgias (TACs) are headaches/facial pains classified together based on: a suspected common pathophysiology involving the trigeminovascular system, the trigeminoparasympathetic reflex and centres controlling circadian rhythms; a similar clinical presentation of trigeminal pain, and autonomic activation. 2. There is much overlap in the diagnostic features of individual TACs. 3. In contrast, treatment response is relatively specific and aids in establishing a definitive diagnosis. 4. TACs are often presentations of underlying pathology; all patients should be imaged. 5. The aim of the article is to provide the reader with a broad introduction to, and an overview of, TACs. The reading list is extensive for the interested reader.

To field-test carefully designed criteria for pain following trigeminal nerve trauma. In order to characterize the clinical phenotype, posttraumatic pain patients were studied and compared with classical trigeminal neuralgia patients (CTN, defined according to the International Headache Society's criteria). Based on etiology and features, trigeminal pain following trauma was defined as "peripheral painful traumatic trigeminal neuropathy" (PPTTN). Data were analyzed with t tests, ANOVA, chi-square, and regression analyses. A total of 145 patients were included: 91 with PPTTN and 54 with CTN. Findings indicated that PPTTN criteria are clinically applicable in the detection and characterization of relevant cases. In contrast to accepted characteristics for PPTTN, the observed profile included both continuous and paroxysmal pain that was stabbing and/or burning. The quality, duration, and intensity were significantly different from the CTN patients (P < .05). PPTTN was consistently accompanied by trigeminal sensory abnormalities (96%) that were mostly allodynia, hyperor hypoalgesia, and only 1% of the PPTTN cases had anesthesia. Overall, the proposed PPTTN criteria have proven to be clinically useful. In view of these results, modified PPTTN diagnostic criteria are proposed for use in future research.

Oral Diseases (2012) 18, 317–332The aim of this article is to review the clinical, pathophysiological, and therapeutic aspects of traumatically induced trigeminal nerve pain. We introduce a new and, in our view, more accurate terminology: peripheral painful traumatic trigeminal neuropathy (PPTTN) to define this patient group. The proposed pathophysiology of PPTTN is largely based on studies in spinal nerve injury models. However, trigeminal nerve injury studies have shown some subtle differences in response to physical and inflammatory insults, and these are discussed. The treatment of painful neuropathies is difficult and carries a poor prognosis. Based on the available literature on efficacy and side effects, we propose a treatment algorithm for traumatic trigeminal neuropathies.

Oral Diseases (2011) 17 (Suppl. 1), 23–41The pathophysiology of persistent orofacial myalgia has been the centre of much controversy. In this article we suggest a novel descriptive term; ‘persistent orofacial muscle pain’ (POMP) and review current evidence that supports the hypothesis that the induction of POMP involves the interplay between a peripheral nociceptive source in muscle, a faulty central nervous system component and decreased coping ability. In this context it is widely accepted that a complex interaction of variable intrinsic and extrinsic factors act to induce POMP and dysfunction.

To assess the prevalence of headaches and painful tempormandibular disorders (TMDs) and examine these via demographic and specific lifestyle parameters, as well as examine the relationship among TMDs, headaches, and depression rates. a group of 359 medical and dental students completed a detailed questionnaire regarding demographic features and the presence of headaches and facial pain. The survey included a section on lifestyle (nutrition, alcohol and tobacco consumption, physical activity) and a Zung depression assessment. about eleven percent of the subjects reported pain: 8.6% from the jaw joint, 1.7% from the muscles of mastication, and 0.8% had both (ie, painful TMD). Eighty-three percent reported a lifetime prevalence of any headache, most of which were episodic tension-type headaches (56.9%) or migraines (19.2%). There was no significant correlation between headache diagnosis and the presence of painful TMD. Patients with painful TMD had higher depression scores than patients without and smoked more tobacco. This was not observed in headache patients. Patients with headache complained of significantly more dizziness and fatigue, particularly in the migraine and frequent episodic tension-type headache groups. TMD patients should be carefully assessed for the presence of emotional problems and referred to a suitable care provider.

To assess the effects of four- and six-point acupuncture on facial sensory detection thresholds to thermal and electrical stimuli. Ten healthy volunteers underwent four-point acupuncture at ST6 and LI4 bilaterally for 15 minutes. A further 10 subjects underwent six-point acupuncture by adding needling at ST2 bilaterally. Sensory testing to thermal and electrical stimuli applied to mental and infraorbital nerve dermatomes was performed at baseline, 10 minutes, 1 hour, and 1 day after needling. In the mental and infraorbital nerve dermatomes, six-point acupuncture significantly increased warm threshold by a peak mean of 1.1°C to 1.4°C (repeated measures ANOVA P = .001) and this effect was significant at all time points relative to baseline (P < .05). No significant effects were observed by the four-point acupuncture on warm thresholds, and neither four- nor six-point acupuncture significantly altered electrical detection thresholds. A dose effect, related to the number of points employed, may be present when employing acupuncture.

Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.