Aim: Paroxysmal hemicrania (PH) is one of the trigeminal autonomic cephalalgias, characterized by severe, strictly unilateral pain attacks lasting 2-30 min localized to orbital, superorbital, and temporal areas accompanied by ipsilateral autonomic features. This pathology shows absolute response to indomethacin. PH may be mistaken for odontogenic pain or temporomandibular disorders, and it is not uncommon for patients to present to dental offices. We report 4 cases of chronic PH (CPH), and discuss with reference to the literature.
Cases: Four patients who fulfilled the criteria for CPH according to the International Classification of Headache Disorders, 2nd edition, attended our orofacial pain clinic between July 1, 2006 and September 30, 2009 (2 men, 2 women). Case 1: A 25-year-old woman presented with pain localized around the right orbit to cheek. Due to a past history of recurrent TMD, CPH was misdiagnosed as exacerbation of TMD. Case 2: A 61-year-old man reported pain as left upper first molar toothache and underwent pulp extirpation. The features of pain were in the zone of overlap between ICHD-II criteria for cluster headache (CH) and PH, leading to misdiagnosis of CH. Case 3: A 57-year-old woman. In the early stage of the disease, the features of pain were in the zone of overlap between PH and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), but the typical clinical picture of CPH became evident over time. She recognized the onset of pain as due to dental treatment. Case 4: A 76-year-old man presented with a case of CPH with concomitant trigeminal neuralgia (CPH-tic syndrome). Both pains completely resolved with indomethacin alone.
Conclusion: As PH patients may present to dental offices, the ability of oral healthcare providers to recognize PH and render an accurate diagnosis with the usage of indomethacin is critical.

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Patient: The patient was a 56-year-old female who complained of burning pain in the left maxillary alveolar area. The pain initiated after periodontal curettage performed without local anesthesia. Extraction of the left first molar temporarily relieved the pain, but pain recurred gradually. Since patient’s signs and symptoms matched the diagnostic criteria for neuropathic pain (Graff-Radford & Solberg, 1992), several medications (tricyclic antidepressant, non-steroidal anti-inflammatory drug, anxiolytics, etc) and cognitive-behavioral therapy were started. To assess symptom severity over a long-term period, daily amount of taken medicines was continuously recorded by the patient in a simple table diary for 8 years. As a result, the total amount of each drug per month gradually decreased with time. However, the pain recurred again and daily amount of taken medicines also increased after 7 years. Then, prescription of pregabalin, which was approved in Japan for management of neuropathic pain in 2010, was initiated. Continuously recorded actual drug consumption status suggested that pregabalin intake dramatically decreased the total amount of taken medicines per month along 3 years. Especially, non-steroidal anti-inflammatory drugs, which were habitually taken by the patient during pain severe periods, became not to be taken at all.
Discussion: While clinical evidence is still lacking regarding the specific treatment modality for neuropathic tooth pain, this sixteen-year long-term pain assessment based on the daily amount of taken medicines suggested a strong analgesic effect of pregabalin.
Conclusion: Despite of fluctuations in pain symptoms by several treatment modalities, this case of neuropathic tooth pain clearly responded to pregabalin treatment.

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Patient: A 56-year-old man complained of pain in the left upper and lower jaw and the left cheek on his first visit to our clinic. The pain was triggered by chewing or speaking and persisted for a few minutes. Magnetic resonance imaging(MRI) scans showed the left trigeminal nerve in contact with the artery and vein at the root entry zone of the nerve. We diagnosed left trigeminal neuralgia (the second and third branches) and prescribed carbamazepine (200 mg/day),and the pain was alleviated. However,a blood examination conducted 6 weeks after treatment initiation revealed hepatic insufficiency. Concurrently, the pain became more severe. Therefore, we prescribed gabapentin（400 mg/day）instead of increasing the carbamazepine dose;subsequently, the pain reduced and liver function normalized. Fourteen weeks after treatment initiation, gabapentin was replaced with pregabalin（150 mg/day）and keishikajyutsubuto（7.5 g/day）,and the patient showed further pain relief. After about 3 weeks,the patient showed drug eruption,and carbamazepine administration was stopped. Although the patient was receiving only pregabalin and keishikajyutsubuto, the pain did not aggravate and the drug eruption disappeared. After about 1 month, keishikajyutsubuto administration was stopped,and the pregabalin dose was increased gradually to 600 mg/day,thereby ensuring pain control. The patient experienced pain relief and the pregabalin dose was decreased gradually.
Seventeen months after treatment initiation, pregabalin administration was stopped,and his treatment was ended the next month.
Discussion: Hepatic insufficiency caused by pregabalin or keishikajyutsubuto is much less frequent than that caused by carbamazepine. Therefore,this drug combination may be useful for treatment of persistent trigeminal neuralgia associated with hepatic insufficiency.
Conclusion: The treatment of mainly using pregabalin is useful for pain control in cases of persistent trigeminal neuralgia associated with hepatic insufficiency.

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Patients: A 27-year-old female complained of pain and paresthesia of upper and lower anterior teeth that began suddenly after dental treatment. After counseling and clinical examination, both somatic disorders (hyperesthesia and temporomandibular disorders) and psychosomatic disorders were suspected. Hyperesthesia and temporomandibular disorders were managed by conservative treatment and counseling, respectively. Regarding psychosomatic disorders, I referred her to a psychologist and we managed together. Our cooperative consultation, psychotherapy and pharmachological management (antidepressants, antianxiety drug) relieved her symptoms in the short term.
Discussion: If we could find no objective finding which explains the subjective symptoms, the patients’ clinical conditions are explained, followed by conservative treatment, rather than actively providing surgical treatment. If necessary, the patients are suggested to consult a psychiatrist for collaboration treatment.
Conclusion: Dentists need knowledge and skill of oral and psychosomatic medicine. The cooperative consultation and treatment with a psychiatrist called “liaison” is necessary for assessment, diagnosis and management of orofacial pain. Around the world, dentists became participants in multidisciplinary approaches to studying these complicated orofacial pains, and multiple evaluation and management are important for patients with complicated conditions as well. Since 2012, the Orofacial Pain Clinic in Nagasaki University Hospital has developed a liaison program pairing dentists with a psychiatrist to treat complicated conditions. (206)

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