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Practical differential diagnosis of chronic craniofacial pain
medicine Editor: JAMES W. LITTLE, D.M.D., M.S.D.
School of Dentistry Universi
Practical differential diagnosis of chronic craniofacial pain James R. Fricton, D. D.S., M.S., * and Richard Kroening, M.D., Ph.D., ** Minneapolis, Minn., and Los Angeles, CaliJ:
Diagnosis of chronic craniofacial pain may be difficult because of the complex psychological and somatic interrelationships of chronic pain, the similarities between diagnoses, and the frequent multiple overlying diagnoses. This article discusses the importance of thorough evaluation and understanding of patients with chronic pain and presents a practical clinical classification of craniofacial pain for systematic differential diagnosis. Examples of the eight groups, with the basic clinical characteristics of each, are presented.
H
ealth care professionals confronted with a chronic craniofacial pain problem that has lasted months to years can be more confident in managing the patient when a correct diagnosis has been made. Through meticulous and conscientious history taking, clinical examination, diagnostic studies, and consultations, this is not only feasible but mandatory for appropriate treatment. Many patients with chronic pain go through unnecessaryrepetitive tests, submit to numerous medical and surgical therapeutic trials, and suffer continued pain as a result of inappropriate or inadequate diagnoses.This will tend to confuse the patient about his or her problem, create further unnecessarypsychological and behavioral problems, and delay the psychological and somatic improvement of the patient. Frustration with the patient may lead the practitioner to overprescribe medication, label the patient as a “hypochondriac,” or refer the patient with a sigh of relief. Part of the *Craniofacial Pain Clinic, Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry. **Pain Management Center, Department of Anesthesiology, University of California at Los Angeles School of Medicine.
628
sixty billion dollars per year that is spent on health services, medications, and lost work by chronic pain patients can be alleviated through proper diagnosis and management.3A Sir William Osler states: “In order to treat something we must first learn to recognize it.” A successful etiologic diagnosis in the case of chronic craniofacial pain is difficult because of the complex psychological and somatic interrelationships of any chronic pain syndrome. Many clinical similarities exist between various possible diagnoses, and many patients with chronic craniofacial pain have two or more overlying diagnoses that can further confuse the practitioner. Both the psychological and somatic aspects of the pain experience should be included in the making of a diagnosis. These would include awareness of the patient’s acquired pain behavior, exploration into reasons for pain reinforcement (operant conditioners), evaluation of psychological and environmental contributing factors, such as stress or diet, and identification of anatomic and physiologic nociceptive processesthat are currently operating. The latter is termed the physical diagnosis. 0030-4220/82/
I20628 + 07$00.70/O @ 1982 The C. V. Mosby Co.
Practical di’erential
Volume 54 Number 6
diagnosis of chronic craniofacial
pain
629
Table I General classification Extracranial structure Intracranial Vascular Myofascial Rheumatic Neuralgic Causalgic Psychogenic
PHYSICAL
I
Origin of pain
I
Craniofacial organs Brain and related structures Vascular system Muscles and fascia Bones, jomts, ligaments Peripheral nervous system Autonomic nervous system Cognitive functioning
DIAGNOSIS(ES)
In order to simplify the process of obtaining a physical diagnosis, a working classification of chronic craniofacial pain is essential (Table I). This classification is a practical synthesis of current thinking on the subject of differential diagnosis of craniofacial pain designed to simplify the process.‘-* It divides pain diagnosesaccording to origin of the pain and affected tissues. The origin of pain generally coincides with the type of tissue affected by the disorder that gives rise to pain. In further analysis of the last six groups, we find that each tissue type develops pain-producing pathosis in a distinct manner, and thus the pain and symptoms associatedwith it generally have similar characteristics and descriptions. These characteristics can be used as significant initial information in arriving at a diagnosis, since the first thing a clinician asks a patient is: “What is your problem?” The patient will then describe the qualities of his or her signs and symptoms and, in particular, the pain. The general description of the pain can lead a clinician to begin thinking in terms of ruling out any general diagnostic group. Once the general diagnostic group is obtained, the specific diagnosis within that group can be deduced with added information from the history, examination, or diagnostic studies. Craniofacial pain can then be divided into eight groups and their usual symptom characteristics (Table I). The extracranial structures group has varied symptoms, the intracranial group also has varied symptoms, the vascular group has throbbing pain, the neuralgic group has both sharp, shooting pain or constant dysesthesia following distinct nerve distributions, the myofascial group has a steady dull ache or tight discomfort, the rheumatic (temporomandibular joint) group has a periauricular ache, the causalgic group has burning hyperesthesia, and the psychogenic group has descriptive global pain. It is important to be aware that the usual symptom of each group still may have varying intensities and
Table II.
Basic characteristic
of pain
Varies Varies Throbbing Steady ache or band Periauricular ache Paresthesia along nerve Burning hyperesthesia Descriptive
History I. 2. 3. 4. 5. 6. 7. 8. 9. IO.
Chief complaints Characteristics of pain Associated symptoms Precipitating or aggravating factors Alleviating factors Onset and history of pain Past and present medications Personal history Medical history Review of systems
verbal descriptors that will add to the difficulty in diagnosing. This systematic approach will help the clinician simplify the task of diagnosing complex chronic pain states. It is particularly helpful in the caseof chronic pain, where frequent multiple diagnoses, complex symptoms, and psychological factors confuse the diagnostic process. In this situation, the differential diagnosescan be arrived at by listening closely to the patient’s description of the various aspects of the pain experience and assessingwhether more than one experience, and hence more than one disorder, is present. For example, a patient may complain of a constant dull ache in front of the ear as well as a paroxysmal lancinating pain that shoots from the ear to the chin and tongue. In this situation, two patterns of pain are described which would lead a clinician to think of ruling out a myofascial or rheumatic diagnosis for the ear pain and the paroxysmal neuralgia group for the shooting pain. Further history, examination, and diagnostic tests will help make more definitive the physical diagnosis of TMJ capsulitis with paroxysmal trigeminal neuralgia. A patient presents with the complaint that “I’m upset about this constant pain all over my head and neck that sometimesgets very bad and I get sick.” In further exploring his symptoms, he describes a periodic pain that begins as a constant throbbing on the
630
Fricton and Kroening
Table
III. Physical examination 1. 2. 3. 4. 5.
Table IV.
Oral Surg. December, 1982
Table V.
Consultants
General inspection General head and neck inspection Neurologic examination Gnathologic examination Muscle and joint palpation examination
I. 2. 3. 4. 5. 6. 7. 8.
Diagnostic studies I. 2. 3. 4. 5. 6. 7. 8. 9. IO. Il. 12. 13.
Radiographs Nerve blocks Gnathologic analysis Pyschological testing Laboratory studies CT scan EEG Angiogram Lumbar puncture Brain scan EMG Thermography Pneumoencephalogram
right hemicranium with associatednausea,vomiting, and photophobia and is preceded by a visual aura and a daily constant, dull ache in the back of the head and neck that radiates to the vertex. The patient describes the pain as getting out of hand to the point where he is very irritable, takes large doses of aspirin and codeine, cannot work, and sits for days in a dark room by himself. Initially, only one pain is described, but further discussion elicits two patterns of pain. After pain associated with extracranial and intracranial structures has been ruled out, pain of vascular origin and pain of myofascial origin need to be ruled out to obtain the correct diagnoses. Further history, examination, and diagnostic tests reveal a classic migraine complicated by myofascial pain of the neck musculature. Here, obvious psychological and behavioral factors tend to complicate the diagnostic processby dominating the history-taking process.Evaluation, diagnosis, and management should consider both the physical and the psychological diagnoses and contributing factors. Knowledge of the general physical diagnostic group is also helpful in determining the somatic treatment that is appropriate. The type of treatment follows naturally from the type of tissue affected and thus the diagnostic group. For example, physical and postural therapy is generally appropriate for all diagnoses within the myofascial group. Psychological or behavioral therapy, such as stress-reduction training or behavior modification, also is essential in managing chronic pain states.
Dentistry Neurology Neurosurgery Otolarynogology Physical medicine Psychiatry Rheumatology Ophthalmology
Establishing a somatic diagnosis or diagnoses will give an appreciation for the somatic changes within tissues that give rise to nociceptive stimuli. Since the pain experience also consists of perception and reaction to the nociceptive stimuli, the evaluation and management of pain problems also have to consider these behavioral and psychological aspects of the patient’s over-all problem. Over-all management can then include attempts to reverse or eliminate the nociceptive pathosis, such as vascular instability in migraines, as well as reduce any perceptual or affective aspectsof the pain problem, such as perceptual enhancement of pain, depression, or sleep disorders. Realization that each aspectof the problem and its management are integrally related to the whole person will greatly facilitate positive progress in improving the patient’s comfort and well-being. KNOWLEDGE
OF THE PATIENT
The fact that many of these patients have failed to respond to traditional management in the past makes it imperative to gain as much knowledge of the patient’s problems as possible in order to diagnose and manage them successfully in the future. This systematic method of differential diagnosis depends on careful listening to the patient. During the diagnostic phase, information about the patient can be gathered from history, physical examination, diagnostic studies, and other consultations. History of the problem will often reveal information that will point directly to a general classification, if not to a specific diagnosis (Table II). Physical examination of the patient should reinforce one’s perceptions about the patient, as well as provide more information on which to base a definitive diagnosis (Table III). Further diagnostic studies, such as radiographs, nerve blocks, and therapeutic trials, can help rule out serious disorders and provide information to complement the history and physical examination findings (Table IV). If doubt concerning the diagnosis persists or a pathologic condition that is out of the clinician’s area of expertise exists, an appropriate consultation can provide additional perspective on the status of the patient (Table V).
Practical di’erential
Volume 54 Number 6
Table VI.
Extracranial structures
pain
63 1
Table VIII
Structures
Diseases
Teeth Periodontium Eye Ear Nose Throat Tongue Sinuses Salivary glands
Infectious Degenerative Edematous Neoplastic Obstructive
Table VII.
diagnosis of chronic craniofacial
Intracranial Traction
Syndromes
Neoplastic Aneurysmal Abscess Hematoma, hemorrhage Edema Angioma
Neurotibromatosis Meningitic Thalamic Phantom
-
As the clinician is obtaining more and more knowledge about the patient and the problem, each general diagnostic group is ruled out with more and more confidence. Head and neck pain resulting from diseasesof extracranial structures or any intracranial pathosis should be ruled out first (Table VI and VII). It is mandatory that organic lesions or pathoses of the teeth, periodontium, eyes, ears, nose, throat, tongue, sinuses,and salivary glands be ruled out. The general practitioner will often be able to rule out this diagnostic group easily, but scrutiny can lead to discovery of a less obvious diagnosis in this group, such as a split-tooth syndrome or mononucleosis. Intracranial disorders are of serious and immediate concern, so it is imperative that this group also be carefully ruled out before one progressesto the other six diagnostic groups. If this has been done, both the patient and the clinician can be more comfortable about progressing with the diagnostic process.After disorders of the extracranial structure and intracranial groups have been ruled out, the history, physical examination, and further diagnostic studies can lead the clinician to choose the correct diagnosis or diagnoses of each of the next five groups (Table VIII). The specific diagnoseslisted in Table VIII are the most common disorders of each group and do not constitute a complete list. Table IX provides the most common diagnoses within each group as well as an overview of the general characteristics of each group. The clinician is advised to supplement this basic information and to
Vascular Migraine: Classic Common Complicated: Ophthalmoplegic/Hemiplegic Cluster headache (ache with throbbing) Cranial arteritis (ache with throbbing) Toxic or metabolic vascular headache Hypertensive headache Carotidynia Myofascial Myofascial pain dysfunction (MPD) Tension headache Mixed tension/vascular Contracture Recurrent spasm Secondary to connective tissue dtsease Rheumatic-temporomandibular joint TMJ capsulitis TMJ derangement/displacement TMJ arthritis: Polyarthritis Septic Traumatic Metabolic Rheumatoid Cervical arthritis Cervical ligament disorder Disorder secondary to rheumatic disease Neuralgic Paroxysmal: Trigeminal Occipital Glossopharyngeal Facial Nervus intermedius Superior laryngeal Eagle’s syndrome Continuous: Postherpetic Posttraumatic Postsurgical Causalgic Posttraumatic reflex sympathetic dystrophy Psychogenic Conversion reaction Somatization Malingerer Munchausen’s syndrome Hypochondriacal reaction Somatic delusion
become more familiar with the specific diagnoses within each group through other sources. If one is comfortable in ruling out each of the first seven diagnostic groups, psychogenic pain can be considered if the following two criteria are met: First, there must be absolutely no physical, neurologic, or musculoskeletal findings that appear to be related to the pain. Second, there must be a definite
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Fricton and Kroening
Table IX.
Oral Surg. December, 1982
Characteristics of eight craniofacial pain groups T I i
Rheumatic (temporomandibular joint)
Extracranial swuclures Varies Related to structure affected Constant, varies Intermittent, progressive
Varies Varies
All ages None Sinus, periodontium, tooth pulp, eye, ear, nose, throat, salivary gland, lymph gland disorders Inflammation, neoplasia, degeneration, obstruction. edema, compression Varies
All ages None Seizures, loss of consciousness; loss of neurologic function; mental and emotional changes Hematoma, hemorrhage, abscess, neoplasm, angioma, aneurysm, edema Movement, straining
Factors that alleviate pain Key diagnostic determinants in addition to characteristics
Varies, reduction of cause Refer to specialist to rule out pathosis
Reduction of cause
Comment
Can display all types of pain
Treatment
Appropriate order
Basic quality Common locations Duration Frequency Onset Common patient Characteristic signs/ symptoms
Factors that precipitate pain
Factors that aggravate pain
for the dis-
Varies Progressive
Anteriogram, EEG, EMI brain scan, radiographs, not relieved with nerve block Should be ruled out first in all cases; urgent management
Neurosurgical
psychological history that would give evidence of a cognitive process where the emotional turmoil is perceived as physical pain. Many clinicians use the term psychogenic to mislabel patients who have a chronic pain problem in which there is a strong emotional or behavioral component and who do not respond well to somatic treatments. It must be emphasized that most persons with chronic pain have an emotional component that affects their behavioral reaction and perception of pain, but the pain is still physical in origin. The muscular tenderness of myofascial pain is frequently overlooked as a positive physical finding and mislabeled as psychogenic pain. There is also a
Steady ache Jaw, head, neck, shoulders; pain can move Varies, constant Fluctuates, nonprogressive All ages Female Limitation of motion, occlusal disharmony, muscle tenderness, autonomic signs, TMJ disorders Stress, tension, bruxism, clenching, trauma, sustained jaw opening, occlusal disharmony Strengthening exercise, immobility, cold weather, systemic disorders, stress Massage, heat, stretching exercise, relaxation Palpation of muscle trigger point and referral of pain; trigger point injection; examination Associated with TMJ disorders, muscle degeneration at site of muscle spindles with referral of pain to distant area Physiotherapy, occlusal therapy, acupuncture, trigger point injection, stress and bruxism reduction, muscle relaxants
Steady ache In ear, periauricular Constant Fluctuates, nonprogressive All ages None Limitations of motion, crepitus, clicking, popping
Aging, repetitive microtrauma. macrotrauma Movement, chewing, occlusal disharmony. yawning Rest, heat, occlusal adjustment Examination, radiograph
Associated with myofascial pain, inflammation or derangement of joint
Stabilization splint and physiotherapy, occlusal rehabilitation, anti-inflammatory drugs, surgery
distinct difference between psychosomatic disorders perpetuated by stress and tensions and the psychogenic pain described here. It is important to realize that, whether or not there is an actual organic basis for the patient’s complaint, it is still very real pain to the patient’s perception and should be respected as legitimate. During the diagnostic phase of interaction with the patient, a skilled clinician can also gain more information about the psychosocial aspects of the patient’s pain. Patients can perceive and respond to pain in varying ways, from gross exaggeration to elaborate denial. It is imperative to listen carefully to all of the patient’s monologue about the pain and its
Practical diferential
Volume 54 Number 6
diagnosis of chronic craniofacial
pain
633
Neuralgic Continuous
Paroxysmal
*
Psychogenic
Sharp shooting Follows nerve distribution
Paresthesia Follows nerve distribution
Burning Area of nerve trauma
Descriptive Unusual distribution
Seconds Intermittent
Constant Fluctuates, nonprogressive
Constant Fluctuates, nonprogressive
Constant Continual
Usually older ages None Trigger area present, related to nerve affected
After nerve damage None Herpetic: history of vesicular eruptions; dysesthesias
All ages None Hyperesthesia, eventual skin tropic changes
Touch or movement of trigger area
Touch, pressure, movement of area
Light touch
All ages Very rare Dull affect, indifferent toward pain, social and occupational incapacitation, life-threatening physical illness or emotional trauma Psychological trauma
Cold wind, activity,
Activity, stress, touch, movement of area
Movement, chewing, occlusal disharmony, yawning
Threatening situation, psychological trauma
Nerve block, avoid stimulating area Nerve block
Nerve block
Relaxation,
Generally none
Compression neuropathy
Damage to nerve due to herpes zoster virus or trauma
Hypersympathetic area of trauma
Carbamazepine 200 mg./day; diphenylhydantoin 200 mg./day, neurosurgery, acupuncture, hypnosis
Amitryptiline 75 mg./day and anticonvulsants; steroid injection early in area for herpes zoster, acupuncture, hypnosis
Stellate ganglion block, hypnosis
stress
Pain distribution,
nerve block
effect on his or her personal life in order to help detect any pain behavior or contributing factors that may perpetuate or aggravate a chronic pain complaint. Psychological testing via the Minnesota Multiphasic Personality Inventory and pain questionnaires, as well as a psychological evaluation, will frequently supplement one’s knowledge about the patient and his or her pain experience. CHRONIC PAIN BEHAVIOR DIAGNOSES
AND PSYCHOLOGIC
Knowledge of the characteristics of patients with chronic pain can help provide full insight into the various behaviors that may complicate or perpetuate
activity
Stellate ganglion block
activity
Rule out all other diagnoses first; not relieved by nerve block; psychiatric history in
Symbolic attempt to solve emotional turmoil is not psychosomatic pain
Supportive therapy, insight psychotherapy
the pain.7,9,‘1-‘3Although we find that a large percentage of our patients with chronic craniofacial pain have physical findings that contribute to their pain complaint, it is unusual to find a chronic pain patient in whom psychological factors are not involved.‘0 Acute pain is self-limiting and temporary, has a specific observable cause and purpose, and generally has no persisting psychological reactions. Chronic pain, in contradistinction, is not self-limiting, appears permanent, has little apparent cause or purpose, and can create multiple psychological problems that can confuse the patient and clinician and perpetuate the problem. A patient may feel helpless,
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hopeless, and desperate in his or her inability to receive relief. Such patients may become hypochondriacal, obsessed,and worried about any symptom or sensation they perceive in their bodies. Vegetative symptoms and overt depressionmay set in, with sleep and appetite disturbances. Irritability and great mood fluctuations are common. Loss of self-esteem, libido, and interest in life’s activities will add to the patient’s misery. All this may erode personal relationships with family, friends, and health professionals. Patients focus all their energy on analyzing the pain problem and believe that it is the cause of all their problems. They shop from doctor to doctor, desperately searching for an organic cure. They can become belligerent, hostile, and manipulative in seeking care. Many clinicians make gallant attempts with multiple drug regimens or multiple surgical procedures, but failure frustrates the clinician and adds to the patient’s ongoing depressionwhile adding dependenciesor the potential for postsurgical complications. Near the end of this progression, many patients with chronic pain can have multiple drug dependencies and addictions, high stress levels, loss of vocation, or permanent disability, or they may be involved in litigation in addition to having their pain problem. Herein lies the importance of proper psychological diagnosis as well as accurate physical diagnosis. An appropriate evaluation should include consideration of all behavioral characteristics that reinforce and perpetuate the pain complaint(s). Obtaining base line measurements of pain levels, drug intake, functional impairment, and emotional state will help the clinician monitor the patient’s progress through rehabilitation. A clinician should elicit and manage factors contributing to pain perpetuation, including stressful events (current and cumulative), interpersonal relationships, secondary gain that the patient may be receiving for having the pain, perceptual distortion of the pain, poor life-style habits (inadequate diet, disturbed sleep, poor posture, lack of exercise), and other acquired negative habits. This information may well point to the reasonswhy the patient has been treated unsuccessfully in the past. The personal history may also point to significant life events that contribute to the development of chronic pain. Long-term rehabilitation of the patient will then include both treatment of the pathosis that is causing the pain and alteration of the psychological and behavioral problems and lifestyle habits that perpetuate the pain problem. Prevention of chronic pain, of course, would be more desirable for the patient and the clinicians.
Oral Surg. December, 1982
SUMMARY
Chronic craniofacial pain afflicts more than one in every ten persons in the United States and Europe. Successful management of chronic craniofacial pain closely follows the thorough evaluation and understanding of the patient and the problem and, subsequently, a correct diagnosis or diagnoses.Evaluation of the patient includes a complete medical, dental, and personal history, physical examination, and appropriate diagnostic studies and consultations. Special consideration should be given the possibility of multiple diagnoses as well as complicating emotional, behavioral, or perceptual factors common in persons with chronic pain. Differential diagnosis is simplified by the use of a practical classification of chronic craniofacial pain. REFERENCES 1. Ad hoc Committee: Classification of Headache, J.A.M.A. 179: 717-718, 1962. 2. Ailing, C. C., and Burton, H. N.: Diagnosis of Chronic Maxillofacial Pain, Ala. J. Med. Sci. IO: 71-82, 1973. 3. Bell, W. E.: Orofacial Pains: Differential Diagnosis, ed. 2, Chicago, 1979, Year Book Medical Publishers, pp 175-254, 322-334. 3A Bonica, J. J.: Preface in Bonica, J. J., Liebeskind, J. C., and Albe-Fessard (editors): Advances in Pain Research and Therapy, New York, 1973, Raven Press, vol. 3, pp. V-VII. Burton, R. C.: The Problem of Facial Pain, J. Am. Dent. Assoc. 79: 93-101, 1969. Dalessio, D. J.: Wolff’s Headache and Other Head Pain, ed. 3, New York, 1972, Oxford University Press. Diamond, S., and Dalessio, D. J.: The Practicing Physician’s Approach to Headache, ed. 2, Baltimore, 1978, Williams 81 Wilkins Company, pp 51-73. 7. Donaldson, D., and Kroening, R.: Recognition and Treatment of Chronic Pain Patients in Dentistry, J. Am. Dent. Assoc. 99: 961-966, 1980. 8. Drinnan, A. J.: Differential Diagnosis of Orofacial Pain, Dent. Clin. North Am. 22: 73-86, 1978. 9. Fordyce, W. E., and Steger, J. C.: Chronic Pain. In Pomerleau, 0. F., and Brady, J.P. (editors): Behavioral Medicine: Theory and Practice, ed. 1, Baltimore, 1978, Williams & Wilkins Company, pp. 125-154. 10. Fricton, J., and Kroening, R.: Statistical Observations of Chronic Head and Neck Pain Patients, UCLA Pain Management Clinic, 1978-80 (unpublished). I I. Kroening, R. J.: Chronic Pain. In Allen, G.D. (editor): Dental Anesthesia and Analgesia: Local and General, ed. 1, Maryland, 1979, Williams & Wilkins Company, chap. 21. 12. Kroening, R. J., Understanding Pain. In Allen, G.D. (editor): Dental Anesthesia: Postgraduate Dental Handbook Series, ed. 1, Littleton, Mass. 1979, Publishing Sciences Group. 13. Sternbach, R. A.: The Psychology of Pain, ed. 1, New York, 1978, Raven Press, chap. I.
Reprint requests to: Dr. James R. Fricton Craniofacial Pain Clinic Department of Oral and Maxillofacial Surgery University of Minnesota School of Dentistry Minneapolis, Minn. 55455
School of Dentistry Universi
Practical differential diagnosis of chronic craniofacial pain James R. Fricton, D. D.S., M.S., * and Richard Kroening, M.D., Ph.D., ** Minneapolis, Minn., and Los Angeles, CaliJ:
Diagnosis of chronic craniofacial pain may be difficult because of the complex psychological and somatic interrelationships of chronic pain, the similarities between diagnoses, and the frequent multiple overlying diagnoses. This article discusses the importance of thorough evaluation and understanding of patients with chronic pain and presents a practical clinical classification of craniofacial pain for systematic differential diagnosis. Examples of the eight groups, with the basic clinical characteristics of each, are presented.
H
ealth care professionals confronted with a chronic craniofacial pain problem that has lasted months to years can be more confident in managing the patient when a correct diagnosis has been made. Through meticulous and conscientious history taking, clinical examination, diagnostic studies, and consultations, this is not only feasible but mandatory for appropriate treatment. Many patients with chronic pain go through unnecessaryrepetitive tests, submit to numerous medical and surgical therapeutic trials, and suffer continued pain as a result of inappropriate or inadequate diagnoses.This will tend to confuse the patient about his or her problem, create further unnecessarypsychological and behavioral problems, and delay the psychological and somatic improvement of the patient. Frustration with the patient may lead the practitioner to overprescribe medication, label the patient as a “hypochondriac,” or refer the patient with a sigh of relief. Part of the *Craniofacial Pain Clinic, Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry. **Pain Management Center, Department of Anesthesiology, University of California at Los Angeles School of Medicine.
628
sixty billion dollars per year that is spent on health services, medications, and lost work by chronic pain patients can be alleviated through proper diagnosis and management.3A Sir William Osler states: “In order to treat something we must first learn to recognize it.” A successful etiologic diagnosis in the case of chronic craniofacial pain is difficult because of the complex psychological and somatic interrelationships of any chronic pain syndrome. Many clinical similarities exist between various possible diagnoses, and many patients with chronic craniofacial pain have two or more overlying diagnoses that can further confuse the practitioner. Both the psychological and somatic aspects of the pain experience should be included in the making of a diagnosis. These would include awareness of the patient’s acquired pain behavior, exploration into reasons for pain reinforcement (operant conditioners), evaluation of psychological and environmental contributing factors, such as stress or diet, and identification of anatomic and physiologic nociceptive processesthat are currently operating. The latter is termed the physical diagnosis. 0030-4220/82/
I20628 + 07$00.70/O @ 1982 The C. V. Mosby Co.
Practical di’erential
Volume 54 Number 6
diagnosis of chronic craniofacial
pain
629
Table I General classification Extracranial structure Intracranial Vascular Myofascial Rheumatic Neuralgic Causalgic Psychogenic
PHYSICAL
I
Origin of pain
I
Craniofacial organs Brain and related structures Vascular system Muscles and fascia Bones, jomts, ligaments Peripheral nervous system Autonomic nervous system Cognitive functioning
DIAGNOSIS(ES)
In order to simplify the process of obtaining a physical diagnosis, a working classification of chronic craniofacial pain is essential (Table I). This classification is a practical synthesis of current thinking on the subject of differential diagnosis of craniofacial pain designed to simplify the process.‘-* It divides pain diagnosesaccording to origin of the pain and affected tissues. The origin of pain generally coincides with the type of tissue affected by the disorder that gives rise to pain. In further analysis of the last six groups, we find that each tissue type develops pain-producing pathosis in a distinct manner, and thus the pain and symptoms associatedwith it generally have similar characteristics and descriptions. These characteristics can be used as significant initial information in arriving at a diagnosis, since the first thing a clinician asks a patient is: “What is your problem?” The patient will then describe the qualities of his or her signs and symptoms and, in particular, the pain. The general description of the pain can lead a clinician to begin thinking in terms of ruling out any general diagnostic group. Once the general diagnostic group is obtained, the specific diagnosis within that group can be deduced with added information from the history, examination, or diagnostic studies. Craniofacial pain can then be divided into eight groups and their usual symptom characteristics (Table I). The extracranial structures group has varied symptoms, the intracranial group also has varied symptoms, the vascular group has throbbing pain, the neuralgic group has both sharp, shooting pain or constant dysesthesia following distinct nerve distributions, the myofascial group has a steady dull ache or tight discomfort, the rheumatic (temporomandibular joint) group has a periauricular ache, the causalgic group has burning hyperesthesia, and the psychogenic group has descriptive global pain. It is important to be aware that the usual symptom of each group still may have varying intensities and
Table II.
Basic characteristic
of pain
Varies Varies Throbbing Steady ache or band Periauricular ache Paresthesia along nerve Burning hyperesthesia Descriptive
History I. 2. 3. 4. 5. 6. 7. 8. 9. IO.
Chief complaints Characteristics of pain Associated symptoms Precipitating or aggravating factors Alleviating factors Onset and history of pain Past and present medications Personal history Medical history Review of systems
verbal descriptors that will add to the difficulty in diagnosing. This systematic approach will help the clinician simplify the task of diagnosing complex chronic pain states. It is particularly helpful in the caseof chronic pain, where frequent multiple diagnoses, complex symptoms, and psychological factors confuse the diagnostic process. In this situation, the differential diagnosescan be arrived at by listening closely to the patient’s description of the various aspects of the pain experience and assessingwhether more than one experience, and hence more than one disorder, is present. For example, a patient may complain of a constant dull ache in front of the ear as well as a paroxysmal lancinating pain that shoots from the ear to the chin and tongue. In this situation, two patterns of pain are described which would lead a clinician to think of ruling out a myofascial or rheumatic diagnosis for the ear pain and the paroxysmal neuralgia group for the shooting pain. Further history, examination, and diagnostic tests will help make more definitive the physical diagnosis of TMJ capsulitis with paroxysmal trigeminal neuralgia. A patient presents with the complaint that “I’m upset about this constant pain all over my head and neck that sometimesgets very bad and I get sick.” In further exploring his symptoms, he describes a periodic pain that begins as a constant throbbing on the
630
Fricton and Kroening
Table
III. Physical examination 1. 2. 3. 4. 5.
Table IV.
Oral Surg. December, 1982
Table V.
Consultants
General inspection General head and neck inspection Neurologic examination Gnathologic examination Muscle and joint palpation examination
I. 2. 3. 4. 5. 6. 7. 8.
Diagnostic studies I. 2. 3. 4. 5. 6. 7. 8. 9. IO. Il. 12. 13.
Radiographs Nerve blocks Gnathologic analysis Pyschological testing Laboratory studies CT scan EEG Angiogram Lumbar puncture Brain scan EMG Thermography Pneumoencephalogram
right hemicranium with associatednausea,vomiting, and photophobia and is preceded by a visual aura and a daily constant, dull ache in the back of the head and neck that radiates to the vertex. The patient describes the pain as getting out of hand to the point where he is very irritable, takes large doses of aspirin and codeine, cannot work, and sits for days in a dark room by himself. Initially, only one pain is described, but further discussion elicits two patterns of pain. After pain associated with extracranial and intracranial structures has been ruled out, pain of vascular origin and pain of myofascial origin need to be ruled out to obtain the correct diagnoses. Further history, examination, and diagnostic tests reveal a classic migraine complicated by myofascial pain of the neck musculature. Here, obvious psychological and behavioral factors tend to complicate the diagnostic processby dominating the history-taking process.Evaluation, diagnosis, and management should consider both the physical and the psychological diagnoses and contributing factors. Knowledge of the general physical diagnostic group is also helpful in determining the somatic treatment that is appropriate. The type of treatment follows naturally from the type of tissue affected and thus the diagnostic group. For example, physical and postural therapy is generally appropriate for all diagnoses within the myofascial group. Psychological or behavioral therapy, such as stress-reduction training or behavior modification, also is essential in managing chronic pain states.
Dentistry Neurology Neurosurgery Otolarynogology Physical medicine Psychiatry Rheumatology Ophthalmology
Establishing a somatic diagnosis or diagnoses will give an appreciation for the somatic changes within tissues that give rise to nociceptive stimuli. Since the pain experience also consists of perception and reaction to the nociceptive stimuli, the evaluation and management of pain problems also have to consider these behavioral and psychological aspects of the patient’s over-all problem. Over-all management can then include attempts to reverse or eliminate the nociceptive pathosis, such as vascular instability in migraines, as well as reduce any perceptual or affective aspectsof the pain problem, such as perceptual enhancement of pain, depression, or sleep disorders. Realization that each aspectof the problem and its management are integrally related to the whole person will greatly facilitate positive progress in improving the patient’s comfort and well-being. KNOWLEDGE
OF THE PATIENT
The fact that many of these patients have failed to respond to traditional management in the past makes it imperative to gain as much knowledge of the patient’s problems as possible in order to diagnose and manage them successfully in the future. This systematic method of differential diagnosis depends on careful listening to the patient. During the diagnostic phase, information about the patient can be gathered from history, physical examination, diagnostic studies, and other consultations. History of the problem will often reveal information that will point directly to a general classification, if not to a specific diagnosis (Table II). Physical examination of the patient should reinforce one’s perceptions about the patient, as well as provide more information on which to base a definitive diagnosis (Table III). Further diagnostic studies, such as radiographs, nerve blocks, and therapeutic trials, can help rule out serious disorders and provide information to complement the history and physical examination findings (Table IV). If doubt concerning the diagnosis persists or a pathologic condition that is out of the clinician’s area of expertise exists, an appropriate consultation can provide additional perspective on the status of the patient (Table V).
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Table VI.
Extracranial structures
pain
63 1
Table VIII
Structures
Diseases
Teeth Periodontium Eye Ear Nose Throat Tongue Sinuses Salivary glands
Infectious Degenerative Edematous Neoplastic Obstructive
Table VII.
diagnosis of chronic craniofacial
Intracranial Traction
Syndromes
Neoplastic Aneurysmal Abscess Hematoma, hemorrhage Edema Angioma
Neurotibromatosis Meningitic Thalamic Phantom
-
As the clinician is obtaining more and more knowledge about the patient and the problem, each general diagnostic group is ruled out with more and more confidence. Head and neck pain resulting from diseasesof extracranial structures or any intracranial pathosis should be ruled out first (Table VI and VII). It is mandatory that organic lesions or pathoses of the teeth, periodontium, eyes, ears, nose, throat, tongue, sinuses,and salivary glands be ruled out. The general practitioner will often be able to rule out this diagnostic group easily, but scrutiny can lead to discovery of a less obvious diagnosis in this group, such as a split-tooth syndrome or mononucleosis. Intracranial disorders are of serious and immediate concern, so it is imperative that this group also be carefully ruled out before one progressesto the other six diagnostic groups. If this has been done, both the patient and the clinician can be more comfortable about progressing with the diagnostic process.After disorders of the extracranial structure and intracranial groups have been ruled out, the history, physical examination, and further diagnostic studies can lead the clinician to choose the correct diagnosis or diagnoses of each of the next five groups (Table VIII). The specific diagnoseslisted in Table VIII are the most common disorders of each group and do not constitute a complete list. Table IX provides the most common diagnoses within each group as well as an overview of the general characteristics of each group. The clinician is advised to supplement this basic information and to
Vascular Migraine: Classic Common Complicated: Ophthalmoplegic/Hemiplegic Cluster headache (ache with throbbing) Cranial arteritis (ache with throbbing) Toxic or metabolic vascular headache Hypertensive headache Carotidynia Myofascial Myofascial pain dysfunction (MPD) Tension headache Mixed tension/vascular Contracture Recurrent spasm Secondary to connective tissue dtsease Rheumatic-temporomandibular joint TMJ capsulitis TMJ derangement/displacement TMJ arthritis: Polyarthritis Septic Traumatic Metabolic Rheumatoid Cervical arthritis Cervical ligament disorder Disorder secondary to rheumatic disease Neuralgic Paroxysmal: Trigeminal Occipital Glossopharyngeal Facial Nervus intermedius Superior laryngeal Eagle’s syndrome Continuous: Postherpetic Posttraumatic Postsurgical Causalgic Posttraumatic reflex sympathetic dystrophy Psychogenic Conversion reaction Somatization Malingerer Munchausen’s syndrome Hypochondriacal reaction Somatic delusion
become more familiar with the specific diagnoses within each group through other sources. If one is comfortable in ruling out each of the first seven diagnostic groups, psychogenic pain can be considered if the following two criteria are met: First, there must be absolutely no physical, neurologic, or musculoskeletal findings that appear to be related to the pain. Second, there must be a definite
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Table IX.
Oral Surg. December, 1982
Characteristics of eight craniofacial pain groups T I i
Rheumatic (temporomandibular joint)
Extracranial swuclures Varies Related to structure affected Constant, varies Intermittent, progressive
Varies Varies
All ages None Sinus, periodontium, tooth pulp, eye, ear, nose, throat, salivary gland, lymph gland disorders Inflammation, neoplasia, degeneration, obstruction. edema, compression Varies
All ages None Seizures, loss of consciousness; loss of neurologic function; mental and emotional changes Hematoma, hemorrhage, abscess, neoplasm, angioma, aneurysm, edema Movement, straining
Factors that alleviate pain Key diagnostic determinants in addition to characteristics
Varies, reduction of cause Refer to specialist to rule out pathosis
Reduction of cause
Comment
Can display all types of pain
Treatment
Appropriate order
Basic quality Common locations Duration Frequency Onset Common patient Characteristic signs/ symptoms
Factors that precipitate pain
Factors that aggravate pain
for the dis-
Varies Progressive
Anteriogram, EEG, EMI brain scan, radiographs, not relieved with nerve block Should be ruled out first in all cases; urgent management
Neurosurgical
psychological history that would give evidence of a cognitive process where the emotional turmoil is perceived as physical pain. Many clinicians use the term psychogenic to mislabel patients who have a chronic pain problem in which there is a strong emotional or behavioral component and who do not respond well to somatic treatments. It must be emphasized that most persons with chronic pain have an emotional component that affects their behavioral reaction and perception of pain, but the pain is still physical in origin. The muscular tenderness of myofascial pain is frequently overlooked as a positive physical finding and mislabeled as psychogenic pain. There is also a
Steady ache Jaw, head, neck, shoulders; pain can move Varies, constant Fluctuates, nonprogressive All ages Female Limitation of motion, occlusal disharmony, muscle tenderness, autonomic signs, TMJ disorders Stress, tension, bruxism, clenching, trauma, sustained jaw opening, occlusal disharmony Strengthening exercise, immobility, cold weather, systemic disorders, stress Massage, heat, stretching exercise, relaxation Palpation of muscle trigger point and referral of pain; trigger point injection; examination Associated with TMJ disorders, muscle degeneration at site of muscle spindles with referral of pain to distant area Physiotherapy, occlusal therapy, acupuncture, trigger point injection, stress and bruxism reduction, muscle relaxants
Steady ache In ear, periauricular Constant Fluctuates, nonprogressive All ages None Limitations of motion, crepitus, clicking, popping
Aging, repetitive microtrauma. macrotrauma Movement, chewing, occlusal disharmony. yawning Rest, heat, occlusal adjustment Examination, radiograph
Associated with myofascial pain, inflammation or derangement of joint
Stabilization splint and physiotherapy, occlusal rehabilitation, anti-inflammatory drugs, surgery
distinct difference between psychosomatic disorders perpetuated by stress and tensions and the psychogenic pain described here. It is important to realize that, whether or not there is an actual organic basis for the patient’s complaint, it is still very real pain to the patient’s perception and should be respected as legitimate. During the diagnostic phase of interaction with the patient, a skilled clinician can also gain more information about the psychosocial aspects of the patient’s pain. Patients can perceive and respond to pain in varying ways, from gross exaggeration to elaborate denial. It is imperative to listen carefully to all of the patient’s monologue about the pain and its
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diagnosis of chronic craniofacial
pain
633
Neuralgic Continuous
Paroxysmal
*
Psychogenic
Sharp shooting Follows nerve distribution
Paresthesia Follows nerve distribution
Burning Area of nerve trauma
Descriptive Unusual distribution
Seconds Intermittent
Constant Fluctuates, nonprogressive
Constant Fluctuates, nonprogressive
Constant Continual
Usually older ages None Trigger area present, related to nerve affected
After nerve damage None Herpetic: history of vesicular eruptions; dysesthesias
All ages None Hyperesthesia, eventual skin tropic changes
Touch or movement of trigger area
Touch, pressure, movement of area
Light touch
All ages Very rare Dull affect, indifferent toward pain, social and occupational incapacitation, life-threatening physical illness or emotional trauma Psychological trauma
Cold wind, activity,
Activity, stress, touch, movement of area
Movement, chewing, occlusal disharmony, yawning
Threatening situation, psychological trauma
Nerve block, avoid stimulating area Nerve block
Nerve block
Relaxation,
Generally none
Compression neuropathy
Damage to nerve due to herpes zoster virus or trauma
Hypersympathetic area of trauma
Carbamazepine 200 mg./day; diphenylhydantoin 200 mg./day, neurosurgery, acupuncture, hypnosis
Amitryptiline 75 mg./day and anticonvulsants; steroid injection early in area for herpes zoster, acupuncture, hypnosis
Stellate ganglion block, hypnosis
stress
Pain distribution,
nerve block
effect on his or her personal life in order to help detect any pain behavior or contributing factors that may perpetuate or aggravate a chronic pain complaint. Psychological testing via the Minnesota Multiphasic Personality Inventory and pain questionnaires, as well as a psychological evaluation, will frequently supplement one’s knowledge about the patient and his or her pain experience. CHRONIC PAIN BEHAVIOR DIAGNOSES
AND PSYCHOLOGIC
Knowledge of the characteristics of patients with chronic pain can help provide full insight into the various behaviors that may complicate or perpetuate
activity
Stellate ganglion block
activity
Rule out all other diagnoses first; not relieved by nerve block; psychiatric history in
Symbolic attempt to solve emotional turmoil is not psychosomatic pain
Supportive therapy, insight psychotherapy
the pain.7,9,‘1-‘3Although we find that a large percentage of our patients with chronic craniofacial pain have physical findings that contribute to their pain complaint, it is unusual to find a chronic pain patient in whom psychological factors are not involved.‘0 Acute pain is self-limiting and temporary, has a specific observable cause and purpose, and generally has no persisting psychological reactions. Chronic pain, in contradistinction, is not self-limiting, appears permanent, has little apparent cause or purpose, and can create multiple psychological problems that can confuse the patient and clinician and perpetuate the problem. A patient may feel helpless,
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hopeless, and desperate in his or her inability to receive relief. Such patients may become hypochondriacal, obsessed,and worried about any symptom or sensation they perceive in their bodies. Vegetative symptoms and overt depressionmay set in, with sleep and appetite disturbances. Irritability and great mood fluctuations are common. Loss of self-esteem, libido, and interest in life’s activities will add to the patient’s misery. All this may erode personal relationships with family, friends, and health professionals. Patients focus all their energy on analyzing the pain problem and believe that it is the cause of all their problems. They shop from doctor to doctor, desperately searching for an organic cure. They can become belligerent, hostile, and manipulative in seeking care. Many clinicians make gallant attempts with multiple drug regimens or multiple surgical procedures, but failure frustrates the clinician and adds to the patient’s ongoing depressionwhile adding dependenciesor the potential for postsurgical complications. Near the end of this progression, many patients with chronic pain can have multiple drug dependencies and addictions, high stress levels, loss of vocation, or permanent disability, or they may be involved in litigation in addition to having their pain problem. Herein lies the importance of proper psychological diagnosis as well as accurate physical diagnosis. An appropriate evaluation should include consideration of all behavioral characteristics that reinforce and perpetuate the pain complaint(s). Obtaining base line measurements of pain levels, drug intake, functional impairment, and emotional state will help the clinician monitor the patient’s progress through rehabilitation. A clinician should elicit and manage factors contributing to pain perpetuation, including stressful events (current and cumulative), interpersonal relationships, secondary gain that the patient may be receiving for having the pain, perceptual distortion of the pain, poor life-style habits (inadequate diet, disturbed sleep, poor posture, lack of exercise), and other acquired negative habits. This information may well point to the reasonswhy the patient has been treated unsuccessfully in the past. The personal history may also point to significant life events that contribute to the development of chronic pain. Long-term rehabilitation of the patient will then include both treatment of the pathosis that is causing the pain and alteration of the psychological and behavioral problems and lifestyle habits that perpetuate the pain problem. Prevention of chronic pain, of course, would be more desirable for the patient and the clinicians.
Oral Surg. December, 1982
SUMMARY
Chronic craniofacial pain afflicts more than one in every ten persons in the United States and Europe. Successful management of chronic craniofacial pain closely follows the thorough evaluation and understanding of the patient and the problem and, subsequently, a correct diagnosis or diagnoses.Evaluation of the patient includes a complete medical, dental, and personal history, physical examination, and appropriate diagnostic studies and consultations. Special consideration should be given the possibility of multiple diagnoses as well as complicating emotional, behavioral, or perceptual factors common in persons with chronic pain. Differential diagnosis is simplified by the use of a practical classification of chronic craniofacial pain. REFERENCES 1. Ad hoc Committee: Classification of Headache, J.A.M.A. 179: 717-718, 1962. 2. Ailing, C. C., and Burton, H. N.: Diagnosis of Chronic Maxillofacial Pain, Ala. J. Med. Sci. IO: 71-82, 1973. 3. Bell, W. E.: Orofacial Pains: Differential Diagnosis, ed. 2, Chicago, 1979, Year Book Medical Publishers, pp 175-254, 322-334. 3A Bonica, J. J.: Preface in Bonica, J. J., Liebeskind, J. C., and Albe-Fessard (editors): Advances in Pain Research and Therapy, New York, 1973, Raven Press, vol. 3, pp. V-VII. Burton, R. C.: The Problem of Facial Pain, J. Am. Dent. Assoc. 79: 93-101, 1969. Dalessio, D. J.: Wolff’s Headache and Other Head Pain, ed. 3, New York, 1972, Oxford University Press. Diamond, S., and Dalessio, D. J.: The Practicing Physician’s Approach to Headache, ed. 2, Baltimore, 1978, Williams 81 Wilkins Company, pp 51-73. 7. Donaldson, D., and Kroening, R.: Recognition and Treatment of Chronic Pain Patients in Dentistry, J. Am. Dent. Assoc. 99: 961-966, 1980. 8. Drinnan, A. J.: Differential Diagnosis of Orofacial Pain, Dent. Clin. North Am. 22: 73-86, 1978. 9. Fordyce, W. E., and Steger, J. C.: Chronic Pain. In Pomerleau, 0. F., and Brady, J.P. (editors): Behavioral Medicine: Theory and Practice, ed. 1, Baltimore, 1978, Williams & Wilkins Company, pp. 125-154. 10. Fricton, J., and Kroening, R.: Statistical Observations of Chronic Head and Neck Pain Patients, UCLA Pain Management Clinic, 1978-80 (unpublished). I I. Kroening, R. J.: Chronic Pain. In Allen, G.D. (editor): Dental Anesthesia and Analgesia: Local and General, ed. 1, Maryland, 1979, Williams & Wilkins Company, chap. 21. 12. Kroening, R. J., Understanding Pain. In Allen, G.D. (editor): Dental Anesthesia: Postgraduate Dental Handbook Series, ed. 1, Littleton, Mass. 1979, Publishing Sciences Group. 13. Sternbach, R. A.: The Psychology of Pain, ed. 1, New York, 1978, Raven Press, chap. I.
Reprint requests to: Dr. James R. Fricton Craniofacial Pain Clinic Department of Oral and Maxillofacial Surgery University of Minnesota School of Dentistry Minneapolis, Minn. 55455