central or peripheral nerve issue?

[tlhappiness]

I have been suffering for 2-1/2 years with oral facial pain.  It began on the left and is now bilateral.  I get severe, constant pain in the upper gums, teeth, cheeks, temples, jaws, neck.  At times there are sharp twinges, but mostly it is a deep, constant ache. I have had close to pain-free moments, but just when i think I'm cured, it flares up.   I have had 2 diagnosis.  TMJ with osteoarthritis of the jaw joints and cervical spine.  The other diagnosis is from a neurologist.  Idiopathic facial pain - Central Nervous System disorder coming fro the brain as opposed to the spine.  I have tried many medications, physio, acupuncture, chiro.  I have been told it is not MS or Trigeminal Neuralgia even though a lot of my pain patterns seem to follow branches of the TN nerves or nucleus from brain, into tmj joint, face, teeth and nucleus at cervical spine.  I have had three neurologists rule on trigeminal neuralgia.  However, couldn't there be nerve impingement somewhere along the trigeminal nerve path?  I have issues in the tmj joints, overactivity of the temporalis and masseter muscles.  I also have cervical spine issues in the C4, 5, 6, 7.  Could that not effect the roots or nucleus of either the trigemal or accessory nerves?  I have looked up central nervous sytem disorders and do not seem to have any of those, so how can this be the origin.  I'm wearing a mouthguard for tmj, and have been doing so for 4 months, but based on this flare-up, questioning that as well.  I can pinpoint some triggers, but this last one seems to coincide with my monthlt cycle and not any particular activity.  I need advice.
Tags: facial pain

[Shazia Alam, DO]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with a doctor.

Without the ability to examine and obtain a history of your mother, I can not tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

There are several “common” pain syndromes of the face, some being different types of headaches.  As you mentioned, one of them is trigeminal neuralgia. This is a type of pain that comes and goes on one side of the face and is severe and sharp when present. When there is no pain, most people are symptom free. It is in the distribution of the trigeminal nerve, hence its name. The pains are usually on the cheek and jaw regions. It usually occurs in people older than 50 years of age. Triggers can include washing the face, shaving, smoking, talking, brushing teeth, etc. The cause is unknown but the thinking is that it is from compression on this nerve. The diagnosis is largely clinical, but MRIs may be obtained to rule out other causes, such as compression or to attempt to identify a cause for the pain, but these tests are most often normal.

Treatment includes medications, such as carbamaezpine, gabapentin, and topiramate, that are used in treating seizures. Many pain medications have indications other than pain treatment. Other options include baclofen or clonazepam. If medical therapy is failed, a referral to a neurosurgeon may be an option for consultation regarding trigeminal nerve decompression or radiofrequency ablation.

Upper cervical lesions can also cause facial pain, if it is affecting some of the fibers affecting the face.  A problem at C4,5,6,7 is less likely to cause these symptoms.  More likely higher up in the C-spine.  

Another condition that should not be overlooked is called giant cell arteritis or temporal arteritis. This condition is due to an inflammation in the temporal artery and other arteries in the body. Symptoms include one sided headache pain in the temple and jaw that may be triggered by chewing. This condition can be diagnosed by a blood test called an ESR and a biopsy of the artery. It is very important to rule this diagnosis out since it is highly treatable and if left untreated it can lead to vision loss. It is exceedingly rare in people younger than 55, and is more common in even older age groups.

I recommend that you follow with your neurologist.  Pain conditions are difficult to treat and may take time. If you have not, I suggest making sure besides TMJ, your teeth are healthy as this can be a large source of referred pain.  

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.

[tlhappiness]

I not sure why a history of my mother is necessary to understand my pain.  3 neurologists and a neurosurgeon looking at my MRI have ruled out Trigeminal Neuralgia.  However, my pain often seems to follow some branches.  I have had 3 dental pain specialists with a CT scan rule out that there is any dental cause.  Any other possible diagnosis besides temporal arteritis....

[tlhappiness]

I not sure why a history of my mother is necessary to understand my pain.  3 neurologists and a neurosurgeon looking at my MRI have ruled out Trigeminal Neuralgia.  However, my pain often seems to follow some branches.  I have had 3 dental pain specialists with a CT scan rule out that there is any dental cause.  Any other possible diagnosis besides temporal arteritis....