Brenda Brown: A 66-Year-Old Bookkeeper With Severe, Shocklike Facial Pain

Brenda Brown

Brenda Brown is a 66-year-old bookkeeper with the chief complaint of “horrible electric shocks in my face.” Brenda stated that for the last 6 weeks, she has been experiencing electric shocks in her right jaw that “come out of nowhere and then go away as quick as they come.” Brenda started crying and said, “Doctor, I just don’t know how much more of this pain I can take! It’s horrible, worse than anything you can imagine.” Between sobs, she said,” I wouldn’t wish this pain on my worst enemy. I can’t eat, drink, or clean my teeth. I’m living on lukewarm oatmeal and even that triggers the shocks.” I asked Brenda if she had ever had anything like this before and she shook her head no. “Any fever or chills?” and again she shook her head no. “Is the pain there all of the time?” I asked. Brenda took a couple of deep breaths in an effort to calm down, then she said, “I am so sorry, Doctor, but I am just so played out. But to answer your question, the pain comes and goes. It hits me out of nowhere. Within a second or two, I am crying out in pain. My face jerks like it’s trying to get away from the pain, and as quick as it comes, it is gone. Then if I sit quietly there is no pain; then out of nowhere, it hits again. It is relentless.”

“Doctor, the pain can hit and wake me up from a sound sleep. If I roll over onto my right side, the touch of the pillow is all it takes to trigger the pain. I have been sleeping in my recliner for the last month. At first, I thought I had a bad tooth, but I went to the dentist and he said he thought the pain was in my nerves. I still have nightmares about the dentist examining me. It was like torture. But honestly, I would let him pull out all of my teeth without local if it would stop this pain.” Brenda started crying again, and the crying triggered paroxysm of pain.

I worked to calm down Brenda, and then asked her to point with one finger to show me where it hurt the most. She pointed to the angle of the right mandible, taking great care not to touch it. “Doctor, this is where the shocks hit, but I really can’t tell where they come from. They come on so fast and with such force that I don’t know which end is up. It takes all of my strength to keep from screaming.”

I told Brenda that we would figure this out and that I would do everything in my power to stop the pain. I asked if I could examine her and she became upset again and said, “Doctor, please don’t touch my jaw! Please don’t. I can’t take much more of this. Go ahead, but please don’t touch my jaw!”

On physical examination, Brenda was afebrile. Her respirations were 18 and her pulse was 84 and regular. Her blood pressure was 148/94. Brenda’s fundoscopic examination was normal as was the remainder of her eye examination. Taking care not to touch her, I had Brenda open her mouth, which triggered another paroxysm of pain. I didn’t see any gross abnormalities, but her dental hygiene was pretty bad. Her cardiopulmonary examination was normal. I did not examine the thyroid or palpate for neck adenopathy in an effort to avoid triggering any more pain. Brenda’s abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the face was normal bilaterally. I noted that Brenda experienced facial tics with the paroxysms of pain. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy. Her deep tendon reflexes were normal, and there were no pathologic reflexes or other abnormalities of the neurologic examination. I told Brenda that I was pretty sure I knew what was going on and that the good news was there were many treatment options to begin immediately. Brenda started crying again and kept saying, “Thank you, God. Thank you, God.”

Key Clinical Points—What’s Important and What’s Not

What Tests Would You Like to Order?

The following tests were ordered:

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  Magnetic resonance imaging (MRI) of the brain with special attention to the brainstem

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  Magnetic resonance angiography (MRA) of the cerebral circulation

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  Erythrocyte sedimentation rate

fClinical Correlation—Putting It All Together

What is the diagnosis?

Trigeminal neuralgia