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  • Facial Pain experts establish a new pain classification.

    The Facial Pain Association and its Medical Advisory Board under the guidance of Dr. Peter J. Jannetta have concluded that the term atypical facial pain be replaced with the term facial pain of obscure etiology.

    Classification of Trigeminal Neuralgia and Other Facial Pain Problems 

    The senior author spent over five months wrestling with the quandary of how to classify our ignorance regarding facial pain as seen by neurologists and neurosurgeons. In his attempt to do this, he enlisted the help of the Medical Advisory Board of the TNA Facial Pain Association. Their input was thoughtful and usually profound and always helpful.

    In days of yore, things we did not understand, both good and bad, were attributed to the workings of the gods in the trees, seas and mountains. This gradually settled onto one Supreme Being before being ascribed, parascientifically, to the psyche. The unknown became psychological and this has become pejorative in most minds.

    On a personal note, as I was combing my way through the literature on the primary etiology of various cranial nerve problems and more recently brain stem vascular compression syndromes, I found that authors did one of two things when they were ignorant. The first (more common) was to expostulate long and hard, confusing etiology with mechanism. This was and is usually unintelligible. The true savant, on the other hand, recognized his ignorance and simply and briefly noted, “we do not know the primary etiology of such and such.”

    Rather than rewriting the Burchiel classification, our consensus was that we should just admit our ignorance. A group of face problems exist without a known primary cause. As optimists, we believe these etiologies will be classified over time. For the present, we should discard the terms atypical and functional from our lexicon. Idiopathic, from the Greek, “it comes from within itself,” implies only that we are ignorant. So be it. We admit this. We need only a non-pejorative term to apply to this group of unclassified problems.

    The term “atypical facial neuralgia or pain” was a wastebasket term applied by a serious contributor of a former era to a group of patients he did not understand. Many of these patients were our trigeminal neuralgia type 2 patients. It is unfortunate that many of these people were told they had psychological problems. Many developed psychological problems after the fact when told by everyone that such was their problem. Over the years, our areas of ignorance have progressively narrowed.

    A non-pejorative and, hopefully, reasonable term for the ever-narrowing group of undiagnosed face pain problems: Facepain of Obscure Etiology (FOE or POE) to replace atypical facial pain in the Burchiel classification.

    Peter J. Jannetta, MD

    John F. Alksne, MD

    Nicholas M. Barbaro, MD

    Jeffrey A. Brown, MD

    Kim J. Burchiel, MD

    Kenneth F. Casey, MD

    Steven B. Graff-Radford, DDS

    Mark E. Linskey, MD

    Donald R. Nixdorf, MD

    Bruce E. Pollock, MD

    David A. Sirois, DMD, PhD

    Joanna M. Zakrzewska, MD




    1. Burchiel, KJ: A New Classification for Facial Pain, Neurosurgery 53:1164-1167, 2003.


    1. Miller JP, Feridun A, Burchiel KJ: Classification of trigeminal neuralgia: clinical, therapeutic, and prognostic implications in a series of 144 patients undergoing microvascular decompression. J Neurosurg 111:1231-1234, 2009.


    1. Zakrzewska JM: Diagnosis and Differential Diagnosis of Trigeminal Neuralgia. The Clinical Journal of Pain 18:14021, 2002 Lippincott Williams & Wilkins, Inc., Philadelphia.


    1. Obermann M, Yoon M-S, Ese D, Maschke M, Kaube H, Diener H-C, Katsarava Z: Impaired trigeminal nociceptive processing in patients with trigeminal  neuralgia. Neurology 2007;69;835-841.


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