Case 7: A Man with Shock-Like Facial Pains

Presenter: Lorin Graef, MD, Chief Resident, Department of Neurology, Johns Hopkins Hospital, Baltimore, MarylandPreceptor: Justin McArthur, MBBS, Professor of Neurology, Johns Hopkins School of Medicine, Baltimore

March 15, 2002

In This Article

Case Presentation

A 42 year-old white man with no significant past medical history developed electric shock-like facial pains ("like a flash camera") in September 1996.


The man's pain radiated from the pre-auricular area of the right ear into the right lower jaw, teeth, and tongue. He initially saw a dentist, who found no pathology and performed no therapeutic procedures. The pains persisted for 1.5 months, then remitted spontaneously.

In March 1997, the patient's pain returned, but it was now more severe, occurring in 5-second intervals throughout the day, and was triggered by facial movement, shaving, speaking, and chewing. Not surprisingly, the patient complained of significant difficulty sleeping. A neurologist prescribed carbamazepine 200 mg 3 times daily. The medicine made him feel "woozy" and "off balance," and provided incomplete pain relief. When the carbamazepine dosage was changed to 400 mg twice daily, the pain lessened somewhat but side effects persisted.

In May 1997, the patient was examined at the Johns Hopkins neurology clinic and was prescribed Tegretol XR (timed-released carbamazepine) 400 mg twice daily. One month later, he reported excellent pain relief with the exception of brief shock-like episodes when he opened his mouth to eat. He no longer experienced any medication side effects.

The patient moved to Texas after which he began to suffer recurrent bouts of pain. A neurologist there increased the timed-released carbamazepine dosage to 700 mg twice daily and added fluorazepam for sleep. Despite these medications, the patient was often unable to eat due to pain.

Upon his return to Baltimore in April 1998, the timed-released carbamazepine dosage was increased to 800 mg twice daily. He was seen in follow-up in January 1999 at which time he was pain-free. A plan was initiated to reduce the timed-released carbamazepine dose by 200 mg/day once a month. However, the patient returned in July 1999 with worsening pain, now involving both the second and third distributions of the trigeminal nerve. Infrequently, he also suffered pains in the first distribution. To seek relief, the patient had self-administered timed-released carbamazepine 400 mg every 3 hours with only mild benefit. Baclofen 10 mg 3 times daily had likewise provided no benefit.

Past History

Medical history. A benign fibroma was removed from an ankle in the 1970s; asthma; seasonal allergies.

Social history. No tobacco or illicit drug use; rare alcohol use. He was self-employed as an interior designer and had no health insurance.

Family history. The patient was adopted and the biological family history was not available.

Physical and Neurologic Examinations

The general physical examination was unremarkable.

The cranial nerve exam was significant only in that painful paroxysms could be elicited by lightly touching the right perioral region. No facial sensory loss was found. Corneal reflexes were intact.

Motor, sensory, reflex, coordination, and gait examinations were normal.


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