General approach to diagnosis and assessment of the facial pain patient

The diagnosis of a cranial neuralgia or neuropathy is clinical and rests on a detailed oral history. A working diagnosis can be obtained using eight yes-or-no questions. Clinical examination apart from sensory testing serves to rule out other facial pain conditions. Magnetic resonance imaging is essential as an aetiological investigation but requires use of specific imaging paradigms that allow visualization of the affected cranial nerve, surrounding blood vessels, and respective root entry zones to detect neurovascular compression. Only magnetic resonance imaging is capable of showing strategically placed brain lesions, such as multiple sclerosis plaques or solitary pontine lesions. Neurophysiological testing employing trigeminal reflexes reveals response abnormalities in practically all cases of secondary trigeminal neuralgia. As important as searching for a clinical diagnosis is assessment of the impact of the pain on the patient’s mood, functionality, and quality of life requires dedicated attention. Use of validated psychometric questionnaires will greatly facilitate this.