Age-Related Pain Syndromes

Eagle's syndrome: Elongation of the styloid process and calcification of the stylohyoid ligament, which commonly occur with aging, uncommonly result in intermittent, sharp pain along the distribution of the glossopharyngeal nerve (ie, in the hypopharynx and base of the tongue). Resection of the elongated styloid process is curative.

Carotidynia: Neck pain with carotid bulb tenderness that is intensified by palpation and head movement is characteristic. This disorder is self-limiting but may last for months. Anti-inflammatory analgesics are effective.

Cervical arthritis: Chronic neck and occipital pain often occurs along the distribution of C2 and C3. In the elderly, this pain must be differentiated from atypical angina pectoris (ie, intermittent, intense exercise-related pain in the neck, throat, or jaw). X-rays should be obtained to differentiate cervical arthritis from bone metastases. Analgesics and a cervical collar can relieve the pain.

Trigeminal neuralgia (tic douloureux): This disorder of the trigeminal nerve produces bouts of excruciating, lancinating pain probably caused by compression of the trigeminal nerve root. Pain occurs along the distribution of the trigeminal nerve and usually lasts between a few seconds and 2 minutes. It is often set off by touching a trigger point or by chewing or brushing the teeth.

No clinical signs accompany trigeminal neuralgia, so finding a sensory or cranial nerve abnormality requires searching for a structural cause of the pain. Differential diagnosis includes neoplasm, vascular malformation of the brain stem, a vascular insult, multiple sclerosis, postherpetic pain, and trigeminal neuropathy with Sjögren's syndrome or rheumatoid arthritis. Migraine may produce atypical facial pain.

Carbamazepine 200 mg tid or qid is generally effective, and the benefit is often sustained; liver and hematopoietic functions should be monitored. If carbamazepine is ineffective or produces toxicity, other options include phenytoin 300 to 600 mg/day, baclofen 30 to 80 mg/day, or a tricyclic antidepressant. Peripheral nerve block provides temporary relief. In resistant cases, a craniectomy can be performed to separate pulsating vascular structures (especially arteries) from the trigeminal root in the posterior fossa. Occasionally, a last resort to relieve intractable pain is resection of the 5th nerve fibers between the gasserian ganglion and the brain stem.