Face and head pain in CCI+AAI

Livy A
Nov 7
5 min read

Some CCI+AAI patients experience head and facial pain, other than the characteristic occipital pain and headaches. Some of the diagnoses given for these include Trigeminal neuralgia (TN), Occipital neuralgia (ON) and Temporomandibular Joint Disorder (TMJD)

Let's take a closer look:

OCCIPITAL NEURALGIA (ON)

Occipital neuralgia is irritation or compression of the occipital nerves — primarily the greater, lesser, or third occipital nerves — which emerge from the upper cervical spine (C2–C3 region) and supply the back of the head and scalp.

Symptoms

Sharp, stabbing, or electric shock–like pain that starts at the base of the skull and radiates up the back or top of the head.
Often one-sided but can be bilateral.
Scalp tenderness, sometimes even pain when brushing hair or resting on a pillow.
May be accompanied by neck stiffness or tightness (especially suboccipital muscles)

ON can be debilitating and things such as wearing a cervical collar can become impossible due to the pain.

Cause and link to CCI+AAI

In craniocervical instability (CCI) and Atlantoaxial instability (AAI), mechanical stress or misalignment at C0–C2 can irritate the C2 dorsal root leading to occipital neuralgia.

Non-surgical treatments

Medication:
Doctors may prescribe over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) or may prescribe muscle relaxants, certain antidepressants, and anticonvulsant medications to manage pain.
Occipital nerve blocks:
A nerve block involves injecting a local anesthetic, often with a steroid, around the occipital nerves. This can provide immediate and temporary relief from pain and inflammation.
Botulinum Toxin (Botox) injections:
Injections of Botox can be used to reduce inflammation of the nerves and provide pain relief.
Heat therapy:
Applying a heating pad to the affected area can help soothe muscle tension and pain.
Physical and massage therapy:
These therapies can help relieve muscle tension in the neck and shoulders that may be contributing to the nerve irritation.

Surgery

Occipital nerve removal, also called occipital neurectomy, is sometimes preformed during fusion surgery, to ensure the patient won't experience pain from ON anymore.

The most common surgery for ON is occipital nerve decompression, a neurectomy is a more aggressive approach:

Instead of decompressing the nerve, the surgeon cuts or removes part of it to stop it from sending pain signals altogether.

Pros:

Can provide long-lasting or permanent relief from severe, intractable pain.

Cons:

Causes numbness in the area the nerve used to supply (back of the scalp).
In some cases, the nerve can regrow abnormally, leading to neuroma pain (a painful lump of nerve tissue).
Because of that, neurectomy is usually reserved for cases where decompression and nerve blocks have failed. However some surgeons use it as a first resort in cases where a craniocervical fusion is also needed.

TRIGEMINAL NEURALGIA (TN)

Trigeminal neuralgia is neuropathic pain involving the trigeminal nerve (cranial nerve V) — which supplies sensation to the face, jaw, and part of the scalp.

Symptoms

Intense, stabbing, electric shock–like facial pain in the distribution of one or more trigeminal branches:
- V1 (ophthalmic): forehead, eye
- V2 (maxillary): cheek, upper jaw
- V3 (mandibular): lower jaw, chin
Attacks last seconds to minutes, often triggered by touch, talking, eating, brushing teeth, or cold wind.
Pain-free intervals between attacks (unlike constant headache pain).

The 3 zones of TN

By Troels Staehelin Jensen.

Licens: CC BY SA 3.0

What is “Atypical” Trigeminal Neuralgia?

Atypical trigeminal neuralgia (ATN) — sometimes called Type 2 TN — is a variant of trigeminal neuralgia where the pain pattern is less classic than in the typical (Type 1) form.
Instead of brief, electric-shock attacks, ATN pain tends to be constant, burning, or aching, often with fewer sharp episodes. It can feel like a mix between neuropathic pain and deep facial soreness.

Cause and link to CCI+AAI

The trigeminal nerve nucleus is a column of gray matter in the brainstem, from the midbrain to the upper spinal cord, that is responsible for sensory and motor functions of the face.

So a hypothesis is that brainstem compression might also lead to compression of the trigeminal nucleus.

Treatments

Anticonvulsants: These are the most common initial treatment, as they are effective at controlling nerve pain. Common examples include carbamazepine (Tegretol), oxcarbazepine (Trileptal), gabapentin (Neurontin), and lamotrigine (Lamictal).
Muscle relaxants: Medications like baclofen may be used alone or in combination with anticonvulsants.

Nerve Blocks & Injections

Used if medication isn’t enough or causes side effects.

Trigeminal nerve block: Anesthetic (like lidocaine) or steroid injection near the nerve root or one of its branches.
Botulinum toxin (Botox) injections: Shown in multiple studies to reduce TN pain for several months; minimally invasive.
Peripheral nerve blocks: Can be done in outpatient settings for temporary relief.

Microvascular Decompression (MVD)

Most effective and durable surgical option for classic TN/TN1.
The surgeon moves or pads away a blood vessel compressing the trigeminal nerve root near the brainstem.
Relieves pressure without damaging the nerve.

Some studies and anecdotal evidence suggests that treating any underlying brainstem compression might relieve the TN type pain.

Temporomandibular Joint Disorder (TMJD)

TMJD — sometimes written as TMD — stands for Temporomandibular Joint Disorder.

It refers to pain or dysfunction in the jaw joint (the TMJ) and the muscles that control jaw movement.

Symptoms

Jaw pain or tenderness (especially near the ears)
Clicking, popping, or grinding when opening or closing the mouth
Limited jaw movement or “locking”
Pain while chewing or talking
Headaches, earaches, or a sense of pressure/fullness near the ear
Pain radiating to the temples, cheek, or neck

Anatomy Link

The trigeminal nerve provides sensation to the TMJ, face, and teeth.
Its mandibular branch (V3) carries sensory fibers from the TMJ capsule and chewing muscles, so irritation in either region can affect the other.
Chronic TMJ inflammation can sensitize trigeminal nerve fibers, leading to burning or shock-like sensations similar to neuralgia.

Comparison: ATN vs TN1 vs TMJD

The symptoms of the above mentioned conditions can be similar but there's some distinction.

Feature	Classic TN (Type 1)	Atypical TN (Type 2)	TMJD (Temporomandibular Joint Disorder)
Pain type	Sudden, stabbing, electric-shock-like	Constant, burning, throbbing, or dull ache (can have occasional sharp flares)	Dull, aching, pressure-like; may radiate to temple, ear, or neck
Pain duration	Seconds to 2 minutes	Continuous (hours to all day)	Constant or intermittent (worsens with jaw use)
Pain-free intervals	Yes (completely pain-free between attacks)	Rare or absent	Often fluctuates, but not completely pain-free
Triggers	Light touch, chewing, brushing teeth, talking, wind	Often spontaneous; sometimes chewing or pressure	Jaw movement, chewing, clenching, stress, wide mouth opening
Location	Usually one side; cheek, jaw, lip, teeth (V2/V3)	Same areas, sometimes broader or deeper	Around jaw joint, temples, ear; can radiate to cheek or teeth
Pain character	Sharp, lightning-like, very brief	Deep, burning, tingling, constant ache	Muscle tension or joint soreness; may have clicking/popping
Associated symptoms	Facial twitching during attacks	Numbness, tingling, burning	Jaw clicking, limited opening, tenderness on palpation
Common cause	Blood vessel compressing trigeminal nerve root	Nerve injury, prolonged compression, post-dental trauma, MS	Joint or muscle dysfunction, clenching, arthritis, bite misalignment