Atypical Facial Pain For several years, Atypical Facial Pain (AFP) represented a set of disorders that included most of the facial pain ailments which did not fit into the category of classic trigeminal neuralgia. As our understanding of the pathophysiology of the many facial pain disorders increased, a new classification for facial pain has been developed which reflected this new knowledge. Thus, terms that were unnecessarily general were left in favor of terminology that was more specific. Presently, AFP is reserved for face pain of psychogenic origin.
Children and adolescents often present to doctors and pediatricians with a variety of medically unexplained symptoms, most common being headache, abdominal, and bone pains. Hence, it’s important to recognize and manage these signs. Atypical facial pain (AFP) or atypical trigeminal neuralgia that has variably been described to be of psychological origin is considered to be uncommon in children. We describe the case of a 13-year-old teenage woman who presented with AFP, who was finally diagnosed to have a somatoform disorder. We talk about the features of AFP in the index case which justify the diagnosis. In addition, we attempt to describe psychosocial variables associated with such a demonstration.
Recurrent medically unexplained symptoms are very frequent in children and adolescents presenting to primary care doctors in addition to pediatricians. ,,, Children may present with a variety of somatic symptoms, the most typical being recurrent headaches, abdominal ache, and bone aches.  These children are at risk of related dysfunction, excessive and unwarranted investigations, and treatment and excessive usage of health-care services. , On the other hand, these somatic symptoms may be a manifestation of underlying gastrointestinal disorder, anxiety disorder or somatoform disorder, and most importantly are the only manifestation. Therefore, it becomes all the more important to comprehend and handle those in child and adolescent patients. Facial pain with no known pathophysiological cause has been clarified variably as a medically unexplained symptom, a diagnosis of exclusion, a psychogenic cause of pain, and even as neuropathy. , Atypical facial pain (AFP) or atypical trigeminal neuralgia has been described in adults and elderly and has been considered to be rare in children.  With this brief background, we now present a case of a teenage girl who presented with atypical hemifacial pain, was originally diagnosed and treated for trigeminal neuralgia prior to being diagnosed as having somatoform disorder.
Miss.. S was 13-year-old and dwelt in an extended family household in a semi-urban region in North India. She had kept nicely until 11 years of age when she started to complain of dull aching, nonradiating, mild to moderate discomfort in the ideal ear every day. She had been given homemade remedies, but to no avail. She often cried and missed school as a result of pain. Two months after, she’d 3–4 episodes in school characterized by unresponsiveness with total awareness of environment, every time for 4 weeks –5 minutes. Teachers advised her to take rest, and she stopped going to school altogether. Electroencephalogram (EEG) (no recording available) performed in this period reported”epileptiform discharges in left hemisphere” and computed tomography scan showed left temporal lobe granuloma. She was given carbamazepine 600 mg/day with a neurologist and parents were informed about”epilepsy.”
The episodes of unresponsiveness subsided, but an earache continued. Parents were quite concerned, especially since they had been told that child had epilepsy. They, especially mother became tolerant if she’d be irritable or demanding, fearing it might worsen her pain. Pain usually occurred about half an hour before leaving school. She missed school. Shortly school authorities complained of poor attendance. Parents blamed them of not cooperating, withdrew her from that school, and admitted her into a local school. Though there was some temporary relief, pain recurred after summer holidays when school reopened. In addition to carbamazepine, pregabalin 75 mg was prescribed. Despite routine compliance for more than two months, no improvement was seen; hence, she had been known for a psychiatry consultation.
When seen in our clinic, it was discovered that although she complained of severe pain, she might be readily engaged in different topics. She had right-sided facial pain and tenderness involving right cheek, submandibular region, angles of mouth and jaw, but sparing lower pinna, side of the nose, lower eyelid, and forehead. Additionally, the right occipital area that is innervated by maxillary and mandibular branches of the facial nerve was also involved. In general, examination suggested that pain did not correspond to the sensory distribution of the trigeminal nerve. Further, history demonstrated that she reported more pain on college days and just before going to college.
She whined that my school isn’t as great as”… (another college ).” She felt ashamed of going to her college. Miss.. S was also temperamentally adamant and didn’t adapt readily. She often demanded for expensive accessories and toys. Grandmother who favored male children over Miss.. S could be exceedingly critical of her. On her part, she harbored extreme anger toward the grandma. Her mother would manage her needs inconsistently and on many occasions meet these with no father’s knowledge. Mother thought that”grandma was being unjust to her kid, so she should look after her.” Repeat EEG revealed no abnormality.
Diagnosis of”Persistent Somatoform Pain Disorder” has been retained. Efforts were made toward building a rapport with her and enhancing her functionality. Amitriptyline 10 mg has been launched originally, and other drugs stopped. She was assured that the healing team believed in the genuineness of pain, but concurrently, the part of focusing attention and distraction in pain perception was highlighted. She was able to link to it and consented to follow straightforward behavioral measures. Task scheduling was done, and she was encouraged to continue with her normal activities despite pain. Her efforts were valued at every trip. Gradually, the focus was shifted on her dealing and frustration tolerance. Parents were also counseled. Miss.. S is on regular follow-up for the last 18 months, doesn’t record pain, off drugs, and routine at school.
AFP refers to pain that doesn’t follow anatomic pathways of cranial or peripheral nerves. , It has no purpose signs, and there’s no obvious explanation for the cause of the pain. Investigations are ordinary, and there is a poor reaction to normal treatments for neuralgic pains. , Also termed, persistent idiopathic facial pain, the pain is felt deep in the soft tissues or the bone, varying from aching or burning to severe throbbing, also is poorly localized. It’s chiefly found on one side of the face. The pain didn’t correspond to the sensory distribution of the trigeminal nerve and didn’t react to Carbamazepine, the standard treatment for trigeminal neuralgia. Thus, the index case presented with what has been described as AFP. Of interest is that AFP is deemed to typically affect middle-aged women and is rare in children.  Our case shows that though uncommon; similar symptoms may occur in children and teens, and clinicians must know about the same.
AFP continues to be variably viewed as being a clinically unexplained symptom to being attributed to muscle activity such as bruxism or a centrally activated autonomic vascular disturbance, demyelination, or infectious causes. ,, However, originally many writers had viewed this illness as a psychosomatic disorder, with a psychogenic origin. , Depression and anxiety are also quite widespread in these individuals.  From the index case, a detailed report revealed that the changes in the pain intensity in relation to school hours.
It was worse during day, absent at nighttime and during school vacations. A similar pattern has been described for other somatoform pain complaints in kids.  in addition, the pain had started and was likely being preserved from the context of their child’s temperament and parental handling. In the light of the AFP at the index child can be considered to be of psychogenic source and provides some limited evidence for emotional causation being among the etiologies of AFP. Furthermore, it increases the literature, a rare demonstration of somatoform pain disorder in children.
As stated previously, AFP does not respond to standard treatments but is revealed to respond to antidepressants, particularly amitriptyline, dossthiepin, and Fluoxetine. ,,, Our patient had pain relief following beginning amitriptyline as well as holding supportive and exploratory sessions with her.
Besides introducing an uncommon manifestation of somatoform disorder in kids, this situation underscores the importance of a good history and examination.
Patients using AFP are thought to have emotional origins of the pain. Depression, unresolved conflicts, behavioral problems, or other psychological issues may come in AFP.
The indications of AFP can be very variable. Patients may clarify burning, aching, cramping, pinching, or pulling sensations. Commonly, symptoms exceed the confines of the trigeminal nerve distribution, or are in nature.
The identification of AFP was created after a formal psychological evaluation, such as a battery of psychometric tests. Additionally, other causes of facial pain, like injuries to the trigeminal nerve or trigeminal neuralgia, must be excluded.
Since the pain out of AFP is psychogenic in origin, psychological support, to include ongoing counseling if needed, is the proper treatment. It’s necessary for both patients in addition to the treating physician(s) to realize that surgery is completely inappropriate for the treatment of this condition.