Other Cranial Neuralgias

Magnetic resonance imaging (MRI), with special attention to this nerve, is indicated to rule out secondary causes, including aberrant blood vessels, multiple sclerosis, or various mass lesions. Medical therapies are similar to those for trigeminal neuralgia. Spontaneous remissions also occur. Medically refractory individuals may require microvascular decompression or an ablative procedure, including a rhizotomy. In most cases, a rhizotomy with surgical division of the glossopharyngeal nerve and the upper rootlets of the vagus nerve provide relief.

OCCIPITAL NEURALGIA

This is a paroxysmal, lancinating pain within the distribution of the greater, lesser, and/or third occipital nerve, often starting at the upper neck or base of the skull and radiating to the back of the head. The stabbing, electric shocklike pain may be provoked by exposure to cold, light touch (i.e., brushing one’s hair, or head and neck movement). Neurologic examination may demonstrate local nerve tenderness and percussion (Tinel sign) and may elicit painful paroxysms or paresthesias along the affected nerve’s cutaneous distribution.

The occipital nerve is derived from the second cervical (C2) root, and therefore pain from C2 will manifest in a similar distribution. Similarly, skull base and upper cervical joint pathology may refer pain to the upper neck and posterior head. A cranial and/or cervical spine MRI focusing on the craniocervical junction is recommended.

An occipital nerve block with local anesthetic and glucocorticoids mixture is often the treatment of choice because this can be both therapeutically and diagnostically useful. After a block, the pain should ease temporarily, sometimes for weeks or months. Pain relief may be accompanied by temporary diminished sensation or dysesthesias within the occipital nerve distribution. Relief with an occipital block should be interpreted with caution because other primary headache syndromes, such as migraine and cluster, are also reported to respond to greater occipital nerve blockade.

LESS COMMON CRANIAL NEURALGIAS

Neuralgic-type pain may arise from any nerve or nerve branch within the head or neck. This includes other nerves derived from the cervical plexus, such as the great auricular nerve, as well as terminal branches of the trigeminal nerve, for instance, supraorbital or infraorbital nerves. Neuralgia may develop spontaneously or subsequent to nerve trauma. The great auricular nerve, carrying lower-ear and jaw-line sensation, may be damaged during parotidectomy, rhytidectomy (face-lift), or carotid endarterectomy.

It is important to inquire about neuropathic in contrast to neuralgic symptoms. Persistent pain or sensory dysfunction, that is, paresthesias, hypoesthesia, or allodynia, suggest neuropathy with underlying nerve damage. If a magnetic resonance image (MRI) is normal, evaluation for connective tissue disease and other inflammatory etiologies should be undertaken.

Two other situations deserve special mention. Persistent unilateral facial pain may rarely be the presenting symptom of lung cancer and is speculated to be due to referred pain from compression or invasion of the vagus nerve. Lung malignancy must be suspected in patients with a smoking history who report new unilateral facial pain or when weight loss or persistent cough is present. A chest x-ray or CT scan of the chest may be diagnostic.

Isolated mental or inferior alveolar nerve neuropathies occur in patients with various metastatic cancers, including hematologic malignancies as well as lung, breast, prostate, and kidney cancers. Patients present with numbness of the chin, lower lip or the gingiva of the lower teeth, with or without associated pain. This “numb chin syndrome” is usually the consequence of bone metastases or leptomeningeal seeding, but it may manifest without obvious cause.

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