Internal Jugular Vein Entrapment: An Underrecognized Cause of Facial Pain

Background: The cause of facial pain often remains unknown after ruling out dental disorders and arterial compression of the trigeminal nerve. New pathologic models and treatment options are needed. Method: Review of 30 patients with unexplained facial pain who were diagnosed with internal jugular vein (IJV) entrapment. Results: Mean age 48.8 ± 12.8 years, duration of symptoms 68.4 ± 100.4 months, women (28/30, 93%). Symptom laterality: left only (11/30, 37%), right only (8/30, 27%), bilateral equally (7/30, 23%), left worse than right (3/30, 10%), right worse than left (1/30, 3%). Facial pain lateralized to the side of underlying venous compression in 19/30 (63%) patients or was unilateral with underlying bilateral compressions in 9/30 (30%). The IJV obstructed at the atlas (lateral process of the atlas, styloid process, posterior belly digastric muscle), between muscles in the mid-neck (sternocleidomastoid, omohyoid, and anterior scalene), and at the thoracic outlet. This led to dilation of the superior petrosal sinus that abuts the trigeminal nerve and shunting through vertebral veins that congested the lower brainstem and cervical spinal cord where the spinal trigeminal nucleus originates and descends. Targeting the IJV obstruction with physical therapy, neurotoxin injections in the neck, and surgical decompression significantly improved facial pain in most patients (20/30, 67%) but was too advanced in some to achieve meaningful relief. Conclusion: Increasing awareness of venous outflow obstruction as a contributor to facial pain could explain complex regional neurological symptoms, provide an option beyond oral medications, and lead to earlier diagnosis when the pathology is amenable to treatment.