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Persistent idiopathic facial pain — Clinical Guidelines

Overview

Persistent idiopathic facial pain (PIFP) is characterized by chronic facial pain without an identifiable organic cause, often challenging to diagnose and manage due to its subjective nature and overlap with other pain conditions 1 7.

Diagnosis

Key Criteria: Female sex, no history of prior sinonasal surgery, low nasal domain score, and high ear/facial domain scores in SNOT-22 questionnaire 1.

Recommended Tests: CT imaging and nasal endoscopy to rule out sinusitis 1.

Additional Considerations: Eye examination to rule out referred pain from ocular structures 8.

Management

First-Line Treatments: Behavioral pain management techniques including activity pacing, relaxation exercises, and cognitive-behavioral strategies 2 4.

Adjunctive Treatments: Cryoanalgesia for non-herpetic neuralgia, with median pain relief lasting 93 days 9.

Surgical Interventions: Endoscopic section of trigeminal root, glossopharyngeal nerve, and cranial vagus for intractable cases, particularly those related to malignancies 10.

Special Populations

Elderly: Unique pain perception and higher prevalence of comorbidities like polypharmacy and dementia necessitate tailored assessment and management approaches 5.

Pregnancy: Specific considerations not addressed in provided abstracts.

Pediatrics: Specific considerations not addressed in provided abstracts.

Key Recommendations

Utilize demographic factors (e.g., female sex, history of sinonasal surgery) and SNOT-22 questionnaire scores to differentiate PIFP from sinusitis [Evidence: Moderate] 1.

Incorporate behavioral pain management techniques as part of comprehensive pain care to enhance functional outcomes and quality of life [Evidence: Strong] 2 4.

Consider interdisciplinary approaches including psychosocial interventions, ensuring they are accessible and reimbursed to improve patient outcomes [Evidence: Expert opinion] 4.

Employ cryoanalgesia for chronic facial pain, particularly non-herpetic neuralgia, given its efficacy in providing prolonged pain relief [Evidence: Moderate] 9.

Evaluate and address unique challenges in older adults, including cognitive impairments and polypharmacy, when managing persistent pain [Evidence: Moderate] 5.

References

1 Altonji S, Del Risco A, Kilpatrick KW, Kuchibhatla M, Abi Hachem R, Jang DW. Predictors of Non-Rhinogenic Facial Pain or Pressure in Otolaryngology Clinic. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2024. link 2 Gerhart J, Ramos K, Porter LS, Ravyts S, Malhotra S, Mossman B et al.. Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain. Journal of palliative medicine 2023. link 3 Flanagan NM. Persistent Pain in Older Adults: Roy's Adaptation Model. Nursing science quarterly 2018. link 4 Janke EA, Cheatle M, Keefe FJ, Dhingra L. Society of Behavioral Medicine (SBM) position statement: improving access to psychosocial care for individuals with persistent pain: supporting the National Pain Strategy's call for interdisciplinary pain care. Translational behavioral medicine 2018. link 5 Molton IR, Terrill AL. Overview of persistent pain in older adults. The American psychologist 2014. link 6 van den Broeke EN, Koeslag L, Arendsen LJ, Nienhuijs SW, Rosman C, van Rijn CM et al.. Altered cortical responsiveness to pain stimuli after high frequency electrical stimulation of the skin in patients with persistent pain after inguinal hernia repair. PloS one 2013. link 7 Pfaffenrath V, Rath M, Pöllmann W, Keeser W. Atypical facial pain--application of the IHS criteria in a clinical sample. Cephalalgia : an international journal of headache 1993. link 8 Kollarits CR. The eye and face pain. Postgraduate medicine 1984. link 9 Barnard D, Lloyd J, Evans J. Cryoanalgesia in the management of chronic facial pain. Journal of maxillofacial surgery 1981. link80024-0) 10 Oppel F, Mulch G, Brock M. Endoscopic section of the sensory trigeminal root, the glossopharyngeal nerve, and the cranial part of the vagus for intractable facial pain caused by upper jaw carcinoma. Surgical neurology 1981. link90102-6)

Persistent idiopathic facial pain