Classification of Facial Pain

General General TN & GPN (Old Site)
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Thought I’d post these two links as well as their content as there is sometimes confusion amongst patients with TN as well as with doctors and specialists.

http://www.fpa-support.org/2011/05/a-new-classification-of-facial-pain-a-patient-oriented-classification-scheme-for-facial-pains-2/

A New Classification of Facial Pain: A patient-oriented classification scheme for facial pains

NOTE: Your doctor or other healthcare professional may not know about or use this classification system. Use it to help you describe your pain. A specific description will help ensure a more accurate diagnosis and more effective treatment.

Anatomy

The trigeminal nerve innervates a portion of the scalp, the face, nose, inside the nose, lips, inside the mouth, part of the tongue, and every tooth in the mouth. However, because the trigeminal nerve is involved does not establish the diagnosis as being TN.

Problem

Often it proves difficult for the physician and patient to determine the fine differences between classic trigeminal neuralgia and trauma induced trigeminal neuropathic pain. IN ORDER, to decide on the proper treatment plan it is imperative to recognize these differences. A destructive procedure used for classic TN could make neuropathic pain much worse.

Clarification

In an attempt to distinguish these differences, Dr. Kim Burchiel, Department of Neurological Surgery, Oregon Health & Science University and a member of TNAs Medical Advisory Board, has developed a patient-oriented classification scheme for facial pains commonly encountered in neurosurgical practice. He notes that this classification is driven principally by the patient’s history.

A new classification for facial pain

Previously, anything other than classic TN used to be lumped into the broad heading of atypical. To be consistent, TNA uses Dr. Burchiel’s classification system, described in Striking Back! The Trigeminal Neuralgia and Face Pain Handbook, which was published by TNA in late 2004. Please be aware that there is not one universally accepted classification for TN and related facial pain conditions. Therefore, your doctor may not identify pain using these same terms.

See this important article on an updated definition of atypical TN:

The Facial Pain Association and its Medical Advisory Board under the guidance of Dr. Peter J. Jannetta have concluded that the term atypical facial pain be replaced with the term facial pain of obscure etiology.

Following are the seven types of face pains that Dr. Burchiel proposes:

Trigeminal neuralgia, type 1, (TN1): facial pain of spontaneous onset with greater than 50% limited to the duration of an episode of pain (temporary pain).

Trigeminal neuralgia, type 2, (TN2): facial pain of spontaneous onset with greater than 50% as a constant pain.

Trigeminal neuropathic pain, (TNP): facial pain resulting from unintentional injury to the trigeminal system from facial trauma, oral surgery, ear, nose and throat (ENT) surgery, root injury from posterior fossa or skull base surgery, stroke, etc.

Trigeminal deafferentation pain, (TDP): facial pain in a region of trigeminal numbness resulting from intentional injury to the trigeminal system from neurectomy, gangliolysis, rhizotomy, nucleotomy, tractotomy, or other denervating procedures.

Symptomatic trigeminal neuralgia, (STN): pain resulting from multiple sclerosis.
Postherpetic neuralgia, (PHN):pain resulting from trigeminal Herpes zoster outbreak. (SHINGLES).
Atypical facial pain, (AFP): is facial pain of unknown origin. *UPDATE – Atypical Facial Pain is an outdated definition and has been replaced with Facepain of Obscure Etiology (FOE or POE).

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And this one…

http://www.fpa-support.org/2011/10/facial-pain-experts-establish-a-new-pain-classification/

Facial Pain experts establish a new pain classification.

The Facial Pain Association and its Medical Advisory Board under the guidance of Dr. Peter J. Jannetta have concluded that the term atypical facial pain be replaced with the term facial pain of obscure etiology.

Classification of Trigeminal Neuralgia and Other Facial Pain Problems

The senior author spent over five months wrestling with the quandary of how to classify our ignorance regarding facial pain as seen by neurologists and neurosurgeons. In his attempt to do this, he enlisted the help of the Medical Advisory Board of the TNA Facial Pain Association. Their input was thoughtful and usually profound and always helpful.

In days of yore, things we did not understand, both good and bad, were attributed to the workings of the gods in the trees, seas and mountains. This gradually settled onto one Supreme Being before being ascribed, parascientifically, to the psyche. The unknown became psychological and this has become pejorative in most minds.

On a personal note, as I was combing my way through the literature on the primary etiology of various cranial nerve problems and more recently brain stem vascular compression syndromes, I found that authors did one of two things when they were ignorant. The first (more common) was to expostulate long and hard, confusing etiology with mechanism. This was and is usually unintelligible. The true savant, on the other hand, recognized his ignorance and simply and briefly noted, “we do not know the primary etiology of such and such.”

Rather than rewriting the Burchiel classification, our consensus was that we should just admit our ignorance. A group of face problems exist without a known primary cause. As optimists, we believe these etiologies will be classified over time. For the present, we should discard the terms atypical and functional from our lexicon. Idiopathic, from the Greek, “it comes from within itself,” implies only that we are ignorant. So be it. We admit this. We need only a non-pejorative term to apply to this group of unclassified problems.

The term “atypical facial neuralgia or pain” was a wastebasket term applied by a serious contributor of a former era to a group of patients he did not understand. Many of these patients were our trigeminal neuralgia type 2 patients. It is unfortunate that many of these people were told they had psychological problems. Many developed psychological problems after the fact when told by everyone that such was their problem. Over the years, our areas of ignorance have progressively narrowed.

A non-pejorative and, hopefully, reasonable term for the ever-narrowing group of undiagnosed face pain problems: Facepain of Obscure Etiology (FOE or POE) to replace atypical facial pain in the Burchiel classification.

Peter J. Jannetta, MD

John F. Alksne, MD

Nicholas M. Barbaro, MD

Jeffrey A. Brown, MD

Kim J. Burchiel, MD

Kenneth F. Casey, MD

Steven B. Graff-Radford, DDS

Mark E. Linskey, MD

Donald R. Nixdorf, MD

Bruce E. Pollock, MD

David A. Sirois, DMD, PhD

Joanna M. Zakrzewska, MD

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Thank you for posting this. Seems we have come a long way in a short while in correctly classifying facial pain. Even just 6 years ago when my pain appeared, it seemed Trigeminal Neuralgia or Atypical Facial Pain were about the only known “diagnosis” around.

I’d say my only question is “Face Pain of Obscure Etiology.” While technically more of an accurate the Atypical Facial Pain, it really still just a wastebasket diagnosis. My suspicion is most of these cases are really Trigeminal Neuropathic Pain or Type 2 TN, but of idiopathic origin.

I have a theory on the cause of some of these spontaneous or idiopathic trigeminal neuropathies (and this is nearly impossible to prove or document in most cases, so it should be taken with a grain of salt)- As we age the body changes and slowly breaks down. Different parts can start pressing on nerves, especially if there was previous injury and canals or nerve pathways were already in a compromised state. Compression neuropathies can be common, such as carpel tunnel syndrome, and many of those cases just appear for no reason other than aging and genetics. I see no reason why the same couldn’t, and isn’t happening on the face. Seems it’s just harder to pinpoint since there are a dozen or so peripheral nerves which run back to the 3 main branches and then the trigeminal nerve root itself. Doesn’t help when practitioners are quick to label it “atypical facial pain.” Well that’s my rant!

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JoeE,
I agree with you, ATN or FOE, kinda feels the same, but at least they’re honest and say they just don’t know …
“Rather than rewriting the Burchiel classification, our consensus was that we should just admit our ignorance. A group of face problems exist without a known primary cause. As optimists, we believe these etiologies will be classified over time”

Also I’ve read about aging and brain sagging as suspected causes for TN in some cases…
There’s still so much we don’t know.

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Thanks so much Mimi. I have read both these before but it is always good to read them over and over again so that we know them by heart and can speak knowledgeably with our GPs, neuros, and NSs. Then it becomes a conversation, and that is a much more powerful position.

Joe, your rant has a lot of value. We all need to learn about “convergence” and how the pain can spread from one area to another because the nerves do “cross-talk”.

Also, it can be helpful for all of us to make really detailed documents of our pain: how it began, how it changed, etc. and also drawings pinpointing the areas and how the pain travels. I have learned to put in all the details, even if it seemed unimportant at the time. Sometimes those little symptoms that we can so easily brush off are actually big clues and helpful for our doctors to understand what we are experiencing.