Chronic mid-facial pain : a randomised clinical trial and a prospective 3 year follow-up

Abstract

Patients often present to otolaryngologists with persistent facial pain, presumed to be of sinus origin despite normal nasal endoscopy and sinus CT scan. The underlying cause has recently been recognized as being of neurological origin, the commonest amoungst which is mid-facial segmental tension-type pain.

This study prospectively followed-up a cohort of 240 patients with chronic facial pain in order to determine the principal causes of pain and long-term patient outcome.

By means of a concurrent randomised single-blind study with parallel design this study also sought to determine whether low-dose amitriptyline is effective in reducing pain

scores compared to surrogate placebo in patients with chronic, tension-type mid- facial segmental pain and whether the addition of pindolol, a beta blocker with

serotonin receptor partial agonistic properties hastens the onset of action or improves the efficacy of amitriptyline.

Sixty two patients were randomised to three treatment groups receiving (a) amitriptyline 10mg daily (b) amitriptyline 10mg daily with pindolol Smg twice daily and (c) loratadine lOmg daily as surrogate placebo. Patients recorded daily pain scores using a facial pain diary over eight weeks.

Both low-dose amitriptyline and amitriptyline with pindolol significantly reduced pain scores compared to placebo. The combination treatment was significantly superior to amitriptyline in reducing analgesic consumption by patients. Following treatment, symptoms resolved in half of the patients with tension-type facial pain at the end of three years. In another third of the patients, their pain significantly decreased in frequency. By means of serial blood serotonin level estimations the clinical trial also investigated whether clinical pain scores could be correlated to changes in serotonin.

Normal women had significantly higher blood serotonin than normal men. The serotonin levels in patients having amitriptyline with pindolol were significantly lower after eight weeks of treatment. A subgroup of women whose pain persisted despite treatment had significantly lower blood serotonin than the women with mid-facial pain.