A 62-year-old man presents with several weeks of excruciating stabbing pain in his right cheek. This pain occurs several times a day, lasts for a few seconds, and is so intense that he often winces or cries out. Episodes of pain can sometimes be caused by touching the face, or by air blowing on his face. What is the most likely diagnosis?
Facial or head pain that is repetitive, severe, stabbing, and lasts just a few seconds is characteristic of the cranial neuralgias: trigeminal, glossopharyngeal, and occipital neuralgia. Of the cranial neuralgias, trigeminal neuralgia (tic douloureux) is the most common and typically occurs in middle-aged patients. Earlier onset can indicate underlying multiple sclerosis. The pain usually occurs unilaterally in the second or third division of the trigeminal nerve and is classically precipitated by light touch of the face. The first-line treatment is carbamazepine, but about one-third of patients do not respond to medical treatment and require invasive management such as microvascular decompression of the trigeminal nerve. Glossopharyngeal neuralgia is much less common, is felt in the throat, and is precipitated by swallowing or yawning. In occipital neuralgia the episodes of pain originate from the base of the skull. Headaches associated with migraine tend to be throbbing and last for hours at a time. Headaches associated with brain tumors are steadily progressive and are often made worse by Valsalva maneuver and by recumbency (i.e., typically worse at night). Carotid artery aneurysms may cause stroke or facial swelling but rarely cause headache.
Carotid artery aneurysm
Migraine
Trigeminal neuralgia
Glossopharyngeal neuralgia
C.N.S.