What could be causing face pain and arm pain with swelling upon waking?

Face and Arm Pain with Swelling Upon Waking: Diagnostic Approach

This presentation requires urgent evaluation for superior vena cava (SVC) syndrome, which can cause facial and arm swelling with pain upon waking due to increased venous pressure in the supine position, though cardiac ischemia and complex regional pain syndrome must also be considered based on the specific distribution and associated features.

Immediate Red Flag Conditions to Rule Out

Superior Vena Cava Syndrome

• Facial and neck swelling with arm involvement is the hallmark presentation, typically worsening when lying flat and improving with head elevation 1
• Patients describe dysphagia, cough, headache, dizziness, and blurred vision alongside the swelling 1
• Physical examination reveals facial edema and plethora, dilated neck veins, and prominent venous pattern on the chest 1
• Head elevation decreases hydrostatic pressure and provides immediate symptomatic relief, confirming the diagnosis 1
• Chest radiograph showing widened mediastinum or right hilar mass supports the diagnosis, though it may appear normal 1
• This is no longer considered a medical emergency, but warrants expedited workup for underlying malignancy 1

Cardiac Ischemia

• Ischemic heart disease can manifest solely as face pain, particularly in the mandibular region and ipsilateral eye, with radiation to the neck 2
• Pain that starts or worsens with physical activity and resolves with rest strongly suggests cardiac origin 2
• Left-sided facial pain with arm involvement requires cardiovascular evaluation, especially with risk factors present 2
• Complete resolution occurs with appropriate cardiac pharmacotherapy when this is the cause 2

Giant Cell Arteritis (Age >50)

• Presents as continuous, dull, aching temporal pain often aggravated by chewing 3
• Associated features include scalp tenderness, visual disturbances, malaise, fever, and elevated ESR/CRP 3
• Requires immediate high-dose corticosteroids to prevent vision loss 3
• Temporal artery biopsy should be performed within 2 weeks of starting treatment 3

Secondary Diagnostic Considerations

Complex Regional Pain Syndrome (Shoulder-Hand Syndrome)

• Can develop after stroke or myocardial infarction, affecting upper extremities with pain, edema, and altered sensations 4
• Presents with painful, edematous arm with altered heat and tactile sensations and dystrophic skin 4
• Diagnosis is clinical with no specific pathognomonic tests 4
• Requires multidisciplinary treatment including pharmacological and non-pharmacological interventions 4

Facial Pain Differential (If Face Pain Predominates)

Temporomandibular Disorders (TMD)

• Most common non-dental cause of facial pain, involving muscles of mastication unilaterally or bilaterally 1
• Associated with clenching, bruxing habits, and jaw clicking or locking 1
• Early diagnosis with reassurance and physiotherapy is effective in patients with good coping strategies 1
• Night splints are commonly prescribed by dentists 1

Trigeminal Neuralgia (If Sharp, Electric Pain)

• Classical presentation: paroxysmal attacks lasting seconds to minutes with mandatory refractory periods 5
• Sharp, shooting, electric shock-like pain triggered by light touch, washing, eating, or brushing teeth 3
• Does not typically cause visible swelling or inflammation 5
• Carbamazepine is the gold standard first-line treatment 5, 3

Trigeminal Autonomic Cephalgias (SUNCT/SUNA)

• Rapid attacks lasting seconds to several minutes with up to 200 attacks daily and no refractory period 5
• Distinguished by autonomic features: tearing, red eye, conjunctival injection, and rhinorrhea 5
• Can be mistaken for trigeminal neuralgia but the autonomic features differentiate them 5

Critical Diagnostic Algorithm

1. Assess swelling distribution and timing:

   • Bilateral facial and arm swelling worse when supine → SVC syndrome 1
   • Unilateral arm swelling with pain → CRPS or vascular obstruction 4
   • Facial swelling with autonomic features (tearing, redness) → SUNCT/SUNA 5

2. Evaluate pain characteristics:

   • Pain with exertion, relief with rest → cardiac ischemia 2
   • Continuous temporal pain with systemic symptoms in age >50 → giant cell arteritis 3
   • Paroxysmal electric shock pain with triggers → trigeminal neuralgia 5, 3
   • Continuous burning pain → neuropathic pain or neuroma 6

3. Immediate investigations based on presentation:

   • Chest radiograph for suspected SVC syndrome 1
   • ESR/CRP for suspected giant cell arteritis in patients >50 3
   • ECG and cardiac enzymes for suspected cardiac ischemia 2
   • MRI for progressive or atypical facial pain to rule out malignancy or structural lesions 1, 5

Common Pitfalls to Avoid

• Do not dismiss bilateral facial and arm swelling as simple edema—always consider SVC syndrome from underlying malignancy 1
• Do not attribute all facial pain in patients >50 to TMD—giant cell arteritis must be excluded to prevent vision loss 1, 3
• Do not assume facial pain is always benign—progressive neuropathic pain can indicate underlying cancer 1
• Obtain histologic diagnosis before treating suspected SVC syndrome, as treatment differs between small cell and non-small cell lung cancer 1
• Wake-up symptoms may indicate stroke, particularly if neurologic deficits are present 7