Facial Pain and Numbness

Sensations of numbness in the face can usually be attributed to some sort of nerve disorder – either damage, irritation or compression, and in the majority of cases will inevitably be accompanied by symptoms of pain. The aetiology of facial numbness and pain are vast, making accurate diagnosis more problematic unless a set of identifiable symptoms are present.

Diagnosis depends very much on associated symptoms, as the origin of the disorder may be due to vascular disturbances, trauma, acute infection (either viral or bacterial), systemic disease such as Multiple Sclerosis, Diabetic Neuropathy, severe anaemia, or malignant processes (cancer or tumour).

Conditions Associated with Facial Numbness

Trigeminal Neuralgia

A specific type of facial pain caused by a disorder of the trigeminal nerve – the largest of the twelve cranial nerves, its function is to supply sensations to the face and mucous membranes as well as motor functions including biting and chewing. Trigeminal neuralgia is characterised by episodes of severe pain on one side of the face only, usually followed by sensations of numbness, tingling or a dull ache.

The most likely cause of the disorder is vascular – an encroaching blood vessel comes into contact with the nerve at a particularly sensitive point, or degeneration of the nerve’s myelin sheath may leave it prone to irritation from nearby blood vessels.  Lesions, tumours and cysts are also possible causes, although less common.

Diagnostic imaging testing with MRI or CT scan of the brain will be necessary to confirm suspected trigeminal neuralgia, and to detect the root cause of nerve compression or irritation.

Trigeminal neuralgia can be treated with specific medication to relieve nerve pain such as carbamazepine or oxcarbazepine. Percutaneous procedures such as radiofrequency lesioning, balloon compression and glycerol injections may be effective, this type of treatment causes deliberate damage to the trigeminal nerve with the aim of disrupting pain signals sent by the nerve, providing pain relief.

In the case of a clear diagnosis where symptoms are caused by nerve compression as a result of blood vessel, surgery can be a curative option – usually microvascular decompression.  In short, this involves locating the offending blood vessel and the trigeminal nerve, making a small incision into the skull and separating the blood vessel from the nerve. This can either be done by placing a small piece of Teflon sponge between the nerve and the blood vessel, or by constructing a sling from adjoining tissue. If the blood vessel has become adhered to the nerve, it may be cauterised and relocated.

Trigeminal Cephalagias

The Trigeminal Autonomic Cephalagias (TACs) include, cluster headache, paroxysmal hemicrania and short-lasting, unilateral, neuralgiform headache attacks with conjunctival tearing (SUNCT) and hemicrania continua.

TACs are a group of primary headache disorders involving the trigeminovascular system and are typically characterised by severe pain felt unilaterally in the face or head, associated with a number of ipsilateral cranial autonomic features such as, ptosis and (drooping of the eyelid), eyelid oedema (swollen eyelid), conjunctival injection (redness in the eye), lacrimation (tearing), facial flushing, facial sweating and rhinorrhoea (runny nose).

Cluster headaches (CH) are the most commonly occurring of the TACs, CH may occur in recurrent bouts lasting from 15 minutes, up to as long as 3 hours in more severe cases. Pain is felt around the temporal and orbital region and is described as excruciatingly painful. During a period of CH, attacks may occur from once a day up to 8 times a day.

Possible treatment may include medication for nerve pain such as Pregabalin, Gabapentin, Tricyclic antidepressants. Occipital Nerve Stimulation, Occipital Nerve Blocks and the use of Botox may also provide pain relief.

Bell’s Palsy

The main cause of facial palsy, (paralysis of the face) Bell’s Palsy is the name of a disorder whereby weakness or paralysis temporarily develops on one side of the face only. In most cases recovery takes place within anything from a few weeks up to nine months.

Bell’s Palsy is due to malfunction of the facial nerve, the seventh cranial nerve –  it is usually a result of irritation or inflammation around the facial nerve. The exact cause is unknown, although it is sometimes linked to viral infections such as herpes, influenza and respiratory illnesses,

The main symptoms of Bell’s Palsy include:

  • partial or complete paralysis of one side of the face including the forehead, this may include feelings of numbness and tingling
  • drooping eyelid or corner of the mouth
  • eye irritation – a dry eye or eye watering
  • sensitivity to loud noise
  • streaming nostril on affected side
  • involuntary drooling
  • ear pain at the onset of symptoms
  • difficulty eating

Some of the symptoms of Bell’s Palsy are similar to those of a stroke, such as the facial paralysis –  although in the case of Bell’s Palsy, facial paralysis includes the forehead, (not usually the case in a stroke), pronunciation of particular letters such as P and B may be affected by Bell’s Palsy, but speech should not be slurred or incoherent as is typical of a stroke,  there is also no weakness of the arms, hands or legs in Bell’s Palsy.

There is no specific test for Bell’s Palsy – diagnosis is usually made by a process of elimination. Typically, in a suspected diagnosis, a neurological examination will be performed and imaging scans such as MRI and CT scans may be needed to exclude other suspected conditions. Blood tests are usually required to rule out other potential causes such as Lyme disease or Ramsay Hunt Syndrome and an electromyography may be requested to determine if facial nerve damage as occurred and if so, to what extent.

Most individuals with Bell’s Palsy make a full recovery, however there are treatments available to speed up the recovery process. These are most effective if administered within 72 hours of the onset of symptoms.

A course of steroid medication, usually Prednisolone may be helpful in reducing the severity of the attack and in some cases, antiviral medication may be administered where viral infection is the suspected cause.

Varicella Zoster (Shingles)

Initial infection of the varicella zoster virus provokes an outbreak of Chicken Pox, upon recovery of the acute symptoms, the virus remains dormant in the immune system for several years. Shingles is the reactivation of the virus, this typically occurs in later life and is characterised by a general feeling of malaise, fever and fatigue followed by painful rash which develops into small blisters – these usually secrete a clear fluid. After a few days, the blisters will begin to scab over and heal, however in a number of cases, symptoms remain in the affected area for weeks after the shingles rash has disappeared. This is described as Postherpetic Neuralgia, and occurs as a result of damage to the sensory nerves caused by the reactivation of the virus.

Shingles and subsequent Postherpetic Neuralgia can manifest on one side of the face and sometimes in one eye (ophthalmic shingles) causing a range of painful symptoms as well as numbness. Ramsay Hunt Syndrome occurs when an outbreak of shingles occurs on the face and affects the facial nerve, this can lead to facial paralysis and hearing loss in the affected ear.

Antiviral medication can be helpful in preventing the virus from multiplying, this is more likely to be effective if taken at the onset of an outbreak of shingles, during the outbreak itself pain relief medication, anti-inflammatory medication and cooling gels may provide relief of acute symptoms. In the case of Postherpetic neuralgia, a number of topical and oral drugs may be administered along with other pain reducing treatments such as Radiofrequency treatment or Botox.

Systemic Disease

Diabetic Neuropathy describes nerve damage caused by diabetes, it can be caused by both type 1 and type 2 diabetes. Over time, excessive glucose levels and high levels of fat in the blood from diabetes may damage nerves and blood vessels. Diabetic Neuropathy is usually characterised into Sensory Neuropathy, Motor Neuropathy and Autonomic Neuropathy.

Symptoms vary greatly depending on the location and function of the nerve(s) affected, frequently described symptoms include numbness, pain and tingling sensations. Diabetes can cause focal neuropathies – this is where damage occurs to single nerves and is usually a result of nerve compression or entrapment. Cranial neuropathies can cause numbness, facial paralysis on one side, as well as painful symptoms in the face and eyes, depending on which nerves are affected.

Diagnosis usually involves a detailed history of symptoms and nerve conduction tests, such as an electromyography. Treatment often focuses on bringing blood sugar levels under control and may include pain relief medication specific to nerve pain, in more severe cases microvascular decompression may be an option.

Multiple Sclerosis (MS) is a condition affecting the central nervous system (CNS) – the body’s immune system mistakenly attacks and damages particular structures and cells within the CNS including the myelin (a protective layer of insulation surrounding nerve fibres), as well as myelin producing cells and underlying nerve fibres. The exact cause of MS is unknown, although it is thought that genetics and environmental factors may be involved.

One of the most commonly reported symptoms of MS include numbness of the face, arms, legs, hands and feet. Other symptoms may include, fatigue, muscle stiffness and spasms, difficulty walking, issues with balance and coordination, weakness, problems with vision, pain and cognitive changes amongst others.

Although there is no current cure for MS, medication is available to manage and improve symptoms. Medication for mild facial numbness is not usually prescribed in cases of MS, however corticosteroids may be prescribed in more severe cases in order to temporarily restore sensation.

Unruptured Brain Aneurysm

A brain aneurysm describes a bulge in a blood vessel, this is caused by a weakness in the blood vessel wall, whereby the blood pressure causes this small area to balloon or bulge outwards. Although an aneurysm could potentially develop anywhere in the body, they are most commonly found in the brain and the heart. If a brain aneurysm ruptures, the bleeding caused by the burst aneurysm causes a subarachnoid haemorrhage (bleeding into the subarachnoid space) – this can cause severe brain damage and has life threatening consequences.

In many cases, brain aneurysms go undetected as they don’t cause any symptoms and not all aneurysms will rupture. However, in some cases, a brain aneurysm may cause other neurological disturbances such as nerve compression or irritation in the brain, resulting in facial numbness and weakness, visual disturbances, headaches, loss of balance, cognitive difficulties/changes, difficulty speaking and pain above and behind the eye.

Immediate medical intervention should be sought in the case of a suspected unruptured aneurysm, it may be treated with either open surgical clipping or endovascular coiling. Following successful surgery, patients will require recovery time in hospital and rehabilitative therapy.

Stroke

A stroke occurs when the blood supply to the brain is disrupted, it is a medical emergency with the onset of symptoms appearing rapidly. Strokes can be caused by ischaemia, restriction of blood supply to an organ or tissue – often caused by a blockage in an artery such as a blood clot, or haemorrhage. Symptoms of a stroke include, facial weakness and partial paralysis – the eyes and mouth of the face may appear to have drooped on one side, numbness may be felt in the face and the body, the individual may not be able to lift both arms, speech may be incoherent or slurred, and the individual may experience dizziness, confusion or a sudden severe headache.

Treatment depends very much on the cause of the stroke. Ischaemic strokes may be treated with alteplase injections to dissolve blood clots (thrombolysis), or in more severe cases a thrombectomy may be necessary. Preventative medications may be prescribed for future use such as anticoagulants and antiplatelets. Haemorrhagic strokes may be treated with surgery to repair burst blood vessels and remove any blood from the brain. The sooner treatment is received in the case of a suspected stroke, the less likely damage is to occur.

Red Flags

Any patients with atypical facial pain and numbness, not easily recognisable by clinicians should have all symptoms thoroughly investigated for signs of a more serious underlying pathology such as cancer or infection.

Pain Management

The pain management clinic specialises in the management of chronic pain related conditions, providing complete all-round treatment by use of a multidisciplinary approach, involving not only pain management consultants, but also psychologists, physiotherapists, surgeons and other health specialists in order to devise an individualised treatment plan. For more information, get in touch today on 020 7060 5109.

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