Intractable facial pain

Case histories of 225 patients with intractable pain attending the Pain Clinic of a large metropolitan teaching hospital were retrospectively analysed. The 29 cases of intractable facial pain were investigated to determine if there were any clinical or historical factors which might indicate intractability and thus speed diagnosis of such cases in future. Significant factors were age, duration of pain, number of surgical interventions and psychiatric factors. Patients with intractable facial pain are more likely to be over 40 years of age, to have pain of long duration, to have had one or more operations, and to require psychiatric assistance than patients with non-intractable facial pain. Temporomandibular joint dysfunction pain and atypical facial pain merged in the intractable state and differ from intractable neuralgias with respect to sex ratio and psychiatric assistance. The incidence of intractable facial pain in South Australia was eight cases per million population per year. Compared to those with intractable pain at other body sites, patients with intractable facial pain have unilateral pain, do not suffer major impairment to their daily lives and are not concerned with monetary compensation. Patients with intractable pain are more likely to show a pattern of organic preoccupation, non-acceptance of reassurance and disease conviction. These findings, together with some current psychiatric aspects of intractable pain, including the concept of illness behaviour, are discussed. It is suggested that early psychiatric assessment will improve management but it is realised that although it is not possible to apply some of the factors studied to each patient, the findings may alert the clinician to potential intractability.