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Neuromodulation for Facial Pain

Progress in Neurological Surgery

Vol. 35

Series Editor

L. Dade Lunsford Pittsburgh, PA

Neuromodulation for Facial Pain

Volume Editor

Konstantin V. Slavin Chicago, IL

52 figures, 30 in color, and 18 tables, 2020


Konstantin V. Slavin

Section of Stereotactic and Functional


University of Illinois College of Medicine

Chicago, IL (USA)

Library of Congress Cataloging-in-Publication Data

Names: Slavin, Konstantin V., editor.

Title: Neuromodulation for facial pain / volume editor, Konstantin V. Slavin.

Other titles: Progress in neurological surgery ; v. 35. 0079-6492

Description: Basel ; Hartford : Karger, 2020. | Series: Progress in neurological surgery, 0079-6492 ; vol. 35 | Includes bibliographical references and index. | Summary: “This book presents a collection of chapters on all kinds of neuromodulation approaches used today in the management of facial pain, providing a comprehensive review of the entire field in a systematic manner”-- Provided by publisher.

Identifiers: LCCN 2020031785 (print) | LCCN 2020031786 (ebook) | ISBN 9783318067941 (hardcover) alk. paper | ISBN 9783318067958 (ebook)

Subjects: MESH: Facial Neuralgia--therapy | Transcutaneous Electric Nerve Stimulation

Classification: LCC RC936 (print) | LCC RC936 (ebook) | NLM W1 PR673 v.35 2020 | DDC 617.5/2--dc23

LC record available at

LC ebook record available at

Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents® and MEDLINE/Pubmed.

Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.

© Copyright 2020 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)

Printed on acid-free and non-aging paper (ISO 9706)

ISSN 0079–6492

eISSN 1662–3924

ISBN 978–3–318–06794–1

e-ISBN 978–3–318–06795–8



Slavin, K.V. (Chicago, IL)

Classification of Facial Pain: A Clinician’s Perspective

Hupe, C.G.; Slavin, K.V. (Chicago, IL)

Anatomy of Trigeminal Neuromodulation Targets: From Periphery to the Brain

Goellner, E. (Porto Alegre); Rocha, C.E. (São Paulo)

Transcutaneous Electrical Nerve Stimulation for Facial Pain

Zayan, K.; Felix, E.R.; Galor, A. (Miami, FL)

Percutaneous Electrical Nerve Stimulation for Facial Pain

Vajramani, G. (Southampton)

Peripheral Nerve Stimulation for Facial Pain Using Conventional Devices: Indications and Results

Winfree, C.J. (New York, NY)

Peripheral Nerve Stimulation for Facial Pain Using Conventional Devices: Technique and Complication Avoidance

Mogilner, A.Y. (New York, NY)

Peripheral Nerve Stimulation for Facial Pain Using Wireless Devices

Stokey, B.G. (Cleveland, OH); Weiner, R.L. (Dallas, TX); Slavin, K.V. (Chicago, IL); Hayek, S.M. (Cleveland, OH)

High-Frequency Peripheral Nerve Stimulation for Craniofacial Pain

Finch, P.; Drummond, P. (Perth, WAU)

Gasserian Ganglion Stimulation for Facial Pain

Yin, D. (Flint, MI); Slavin, K.V. (Chicago, IL)

Sphenopalatine Ganglion Stimulation for Chronic Headache Syndromes

Vesper, J.; Santos Piedade, G.; Hoyer, R.; Slotty, P.J. (Düsseldorf )

Transcranial Direct Current Stimulation in the Treatment of Facial Pain

Antal, A. (Göttingen)

Transcranial Neurostimulation (rTMS, tDCS) in the Treatment of Chronic Orofacial Pain

Fricová, J.; Rokyta, R. (Prague)

Cervical Spinal Cord Stimulation for Facial Pain

Jones, M.R.; Baskaran, A.B.; Rosenow, J.M. (Chicago, IL)

Deep Brain Stimulation for Facial Pain

Singleton, W.G.B.; Ashida, R.; Patel, N.K. (Bristol)

Motor Cortex Stimulation for Facial Pain

Teton, Z.E.; Raslan, A.M. (Portland, OR)

Neurosurgical Management of Cancer Facial Pain

Mirzadeh, Z.; Sheehy, J.P. (Phoenix, AZ); Ben-Haim, S. (La Jolla, CA); Rosenberg, W.S. (Kansas City, MO)

Targeted Drug Delivery (Intrathecal and Intracranial) for Treatment of Facial Pain

Dupoiron, D. (Angers)

Author Index

Subject Index


Published online: July 22, 2020

Slavin KV (ed): Neuromodulation for Facial Pain. Prog Neurol Surg. Basel, Karger, 2020, vol 35, pp VII–VIII (DOI: 10.1159/000509487)



Konstantin V. Slavin

Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA

Perhaps the most unique and just as important part of the human anatomy, the face represents less than 5% of the body surface area in an adult and its sensation is primarily supplied by a single cranial nerve on each side, the trigeminal nerve, with only minor contributions from multiple secondary nerves. In the central nervous system, however, the face is represented in a rather complex and disproportionally large manner, and this complexity correlates with the high prevalence, major psychological impact, and great diversity of various pain syndromes that involve face and facial structures.

Along with many clinical conditions that present with facial pain and a multitude of relevant pain types, there are different treatment approaches including variety of interventional modalities and surgical procedures that are aimed at the extracranial and intracranial components of the trigeminal system. These interventions and surgeries are not chosen arbitrarily, but are based on very specific indications, and the escalating degree of invasiveness dictates the sequence in which these approaches are chosen. As a matter of fact, in our routine neurosurgical practice we tend to follow a certain algorithm that facilitates the choice of appropriate procedure based on a straightforward set of clinical features [1].


In a field of pain surgery, as in most areas of functional neurosurgery, the interventions are divided into decompression, ablation and modulation, and when decompression is not an option or if it fails, one has to choose between advantages and disadvantages of either precise and focused destruction or a nondestructive alternative of neuromodulation. Recently, neuromodulation has become more of a mainstream of pain surgery; as the matter of fact, it in essence replaced most neuroablative interventions. This trend toward preferred use of neuromodulation is, indeed, reaching the way we approach management of facial pain, and the long list of available neuromodulatory interventions is getting longer, targeting every component of the trigeminal nociceptive system.

For most of us, in and out of neurosurgical community, facial pain does not come to mind as a main indication for neuromodulation – as the matter of fact, the vast majority of neuromodulation interventions are done for patients with pain in the lower back and the extremities. The deep brain stimulation is used mainly for treatment of movement disorders, and cranial nerve stimulation – for epilepsy and depression. However, if one looks at the history of neuromodulation, facial pain was by far the first indication for implanted electrical stimulators when Shelden et al. [2] in 1962 operated on 3 patients with facial pain and placed silicone electrodes around their trigeminal branches even before the gate-control theory was published by Melzack and Wall in 1965 [3] and the first spinal cord stimulator was implanted by Shealy in 1967 [4]. Similarly, many years before stimulation of sensory ganglia became mainstream in the treatment of bodily pain, neurosurgeons were using Gasserian ganglion stimulation for the treatment of facial pain in late 1970s [5]. And the list goes on.

This book presents a collection of chapters on all kinds of neuromodulation approaches used today in the management of facial pain in an attempt to provide a comprehensive review of the entire field in a systematic manner. For neuromodulation practitioners and all other specialists who treat facial pain it may be interesting to learn about advances in facial pain classification, use of noninvasive neuromodulation, early experience with innovative technology used for neuromodulation, as well as technical aspects, patient selection, and complication management for specific applications of electrical and chemical neuromodulation that are currently available for clinical use. The volume follows the long tradition of the Karger’s series Progress in Neurological Surgery to focus on the cutting edge of neurosurgical research and innovation.


1Slavin KV, Nersesyan H, Colpan ME, Munawar N: Current algorithm for the surgical treatment of facial pain. Head Face Med 2007;3:30.

2Shelden CH, Pudenz RH, Doyle J: Electrical control of facial pain. Am J Surg 1967;114:209–212.

3Melzack R, Wall PD: Pain mechanisms: a new theory. Science 1965;150:971–979.

4Shealy CN, Mortimer JT, Reswick JB: Electrical inhibition of pain by stimulation of the dorsal columns. Preliminary clinical report. Anesth Analg 1967;46:489–491.

5Myerson BA, Hakansson S: Alleviation of atypical trigeminal pain by stimulation of the Gasserian ganglion via an implanted electrode. Acta Neurochir Suppl (Wien) 1980;30:303–309.

Konstantin V. Slavin

Department of Neurosurgery, University of Illinois at Chicago

912 S. Wood Street, M/C 799

Chicago, IL 60612 (USA)

Published online: July 31, 2020

Slavin KV (ed): Neuromodulation for Facial Pain. Prog Neurol Surg. Basel, Karger, 2020, vol 35, pp 1–17 (DOI: 10.1159/000509652)


Classification of Facial Pain: A Clinician’s Perspective

Christy A. Gomez HupeKonstantin V. Slavin

Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA



Successful management of facial pain starts with making correct diagnosis. Diagnostic errors, particularly early on in evaluation of facial pain patients are not uncommon, and some of this may be related to the lack of uniform classification that would satisfy needs of different specialists. Here, we critically review several most common classification schemes and try to compare and contrast their strength and unique features. We also attempt to link multiple terminologies describing same clinical conditions and provide a rationale for developing a unified nosological approach. Based on our findings, we conclude that despite many previous attempts, much work needs to be done to create a universally accepted, comprehensive but at the same time simple and user-friendly, facial pain classification, with the ultimate goal of integrating such classification into a treatment-guiding algorithm(s).

© 2020 S. Karger AG, Basel


Neuromodulation can be an excellent choice for the treatment of facial pain, but a precise formulation of correct diagnosis is critical to positive outcomes. Facial pain, as is widely quoted, may affect up to 26% [1] of the population and is frequently severe and debilitating. The general term “facial pain” encompasses a wide range of conditions and, although presentations may be similar, the nuances indicate significant variations which will be more or less responsive to different management strategies – neuromodulation in particular. Familiarity with classification systems for facial pain helps the clinician in careful assessment and proper selection of patients that may be appropriate candidates for neuromodulatory intervention. Further, a clear understanding of facial pain syndromes provides a basis for reasonable pain relief expectations following intervention.

Table 1. Comparative table of facial pain classifications

In addition to guiding treatment, a clear use of definitions and terminology facilitates communication between multiple specialists, from different professional backgrounds, and with the patients. It is not uncommon to see individuals with long standing facial pain presenting without ever having received a clear diagnosis, despite seeing multiple providers about their complaint. Having a clear diagnosis, for which there are specific therapeutic treatment options, may itself be a source of relief for these patients. Lastly, standardized terminology and classification are essential if we hope to expand the field with research, compare meaningful data, and investigate new treatment modalities.

In this chapter, we review the current, most common, classification systems while discussing individual facial pain syndromes. Emphasis is placed on conditions that are amenable to intervention, particularly neuromodulation.

Classification Strategies

There are many etiologies of, or mechanisms that result in, facial pain. These include, but are not limited to acute injury, post-traumatic sequelae, inflammation, neurogenic dysfunction (both peripheral and central), or idiopathic [2]. The most common classification systems use etiology and anatomy as the basis for classification strategies, in some cases grouping facial pain with headache or oral pain. Widely recognized and recently updated classifications include (Table 1):

1International Classification of Headache Disorders (ICHD) – created by the International Headache Society (IHS). The latest edition, ICHD-3, was published in 2018 [3].

2Classification of Chronic Pain – from the International Association for the Study of Pain (IASP). Second Edition was published in 2011, with ongoing updates [4].

3International Classification of Diseases (ICD) coding – by the World Health Organization (WHO). Current version is ICD-11, released in May of 2019 [5].

4Classification from the American Association of Orofacial Pain (AAOP), 6th edition, published in 2018 [6].

5Clinical classifications of trigeminal pain by Burchiel [7] published in 2003 and by Cruccu et al. [8] published in 2016.

The first comprehensive multiaxial classification system for chronic pain syndromes in all body regions including face, head, and neck was put together by IASP in 1986 [9]. This has since been updated on multiple occasions, last time officially published in 2011 but now updated online on an ongoing basis. While the goal was to classify chronic pain conditions, it also included some acute conditions as a means of contrast. This classification groups pain syndromes into generalized or localized conditions and eight major categories.

Conditions that include facial (and oral) pain are in seven subcategories under the major category “Relatively localized syndromes of the head and neck.” Facial neuralgias, pain of musculoskeletal origin, lesions of ear, nose and oral cavity, primary headache syndrome, and vascular disorders causing face pain and pain of psychological origin are included in this taxonomy under separate headings. Each diagnosis is accompanied by a full description, proposed diagnostic criteria and a standardized coding system [4]. Some better-known conditions are also accompanied by information including usual course, precipitation, associated signs and symptoms, differential diagnoses and methods or relief. Certain, less common, conditions such as hypoglossal neuralgia are simply accompanied by a code (Table 2).

The ICHD classification was first published in 1988. The preface of the initial publication noted that it largely relied on the experience of experts in absence of published evidence. The stated expectation was that the existence of operational diagnostic criteria would generate research interest leading to improvements in later editions [10]. ICHD-II, published in 2004, included a number of changes including new evidence and the revised opinions of experts. ICHD-3 Beta, published in 2016, had scientific evidence playing a greater role and all subsequent changes included in the current (2018) ICHD-3 are stated to be based on such evidence. The IHS has voiced a strong commitment that the headache classification “is now and in the future will be driven entirely by research” [3] (Table 3).

The ICHD classification, similarly to IASP, includes a description and specific diagnostic criteria for every disease entity. Many of the conditions offer comments related to differential diagnoses or common associated features. Importantly, unlike the IASP, it does not offer insight into management strategies.


The ICD-11 is a medical classification by the WHO. It is the eleventh revision of the ICD [5]. The ICD system is very familiar to most clinicians as it contains codes for diseases and is used as the standard diagnostic tool for epidemiology and clinical diagnosis, particularly in reimbursement and data storage. However, for clinicians treating facial pain conditions or researchers attempting to study them, the lack of adequate coding in the earlier ICD version (ICD-10) has been a major obstacle. ICD-11, presented to and adopted by the WHO assembly in May of 2019, represents a major revision answering some of the earlier concerns [11, 12].

Table 2. IASP Classification

The IASP created a working group on the classification of chronic pain in 2013 that works closely with the WHO to improve the classification of pain conditions in order to promote a more standardized approach to be reflected in the subsequent revisions. An example of their collaboration relevant to this subject is that in ICD-11 chronic neuropathic pain is now represented with its own code [4].

The AAOP classification was first published in 1990, originally limited in focus to the diagnosis and management of temporal mandibular disorders (TMD). The second through sixth editions (2018) have expanded the guidelines for assessment, diagnosis, and management to include all clinical presentations of oral facial pain (OFP)-related disorders [6]. This guideline does not provide a different classification system of OFP disorders other than for TMD, however, it informally provides a classification scheme based on its organization that uses a topographical approach and various tissues, structures, and organ systems that can be involved with craniofacial and oral pain. A listing of the chapter headings (Table 4) presents an overview of the scheme. Importantly, these guidelines endorse the use of the ICHD classification in reference to neuropathic pain and primary headache disorders.

Table 3. ICHD-3 Classification

Table 4. AAOP Chapter Headings

Table 5. Burchiel Classification

Fig. 1. Cruccu classification of trigeminal neuralgia (modified from Cruccu et al. [8]).

While the aforementioned classification systems address facial pain syndromes among broader categories and with complex coding strategies, the Burchiel classification specifically addresses facial pain in the trigeminal nerve distribution [7]. Significantly simpler than the other classifications, the seven categories presented are well defined by symptoms and history (Table 5).

Somewhat similar to the Burchiel classification, the classification by Cruccu et al. [8] is limited specifically to trigeminal neuralgia, representing a product of an expert group convened with endorsements from the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain and the Scientific Panel Pain of the European Academy of Neurology. Three diagnostic categories are proposed: Classical, Secondary, and Idiopathic Trigeminal Neuralgia. This system bases diagnosis on location and nature of painful paroxysms and identification of the underlying cause. This classification uniquely goes beyond the symptoms to differentiate Classic TN as having a vascular compression shown on MRI versus idiopathic TN which does not [8] (Fig. 1).

Much work has been done regarding the classification of facial pain over the last 30 years. As a result, the current classifications are more similar than different, and while still far from perfect, provide insight for the clinician seeking to provide a precise diagnosis.