Pain from head and neck cancer — and from the treatment for it — is among the hardest pain in medicine to control, and one of the few places in this clinic where opioids are part of the answer.
Where the pain comes from
It usually has more than one source at once, which is why single-agent approaches disappoint:
- The tumour itself — invading or compressing nerve, bone or soft tissue.
- Surgery — neck dissection in particular, which can leave lasting shoulder and cervical pain and injury to the spinal accessory nerve.
- Radiation — acute mucositis during treatment, and later fibrosis, trismus and neuropathy that can appear months or years afterwards.
- Chemotherapy — peripheral neuropathy.
Some of it is nociceptive and some neuropathic, and the two do not respond to the same things.
Opioids here are appropriate
Opioids are a poor choice for migraine and for most primary headache, for reasons of efficacy and rebound. Cancer pain is a different clinical problem and a different calculation. Opioids are a legitimate and often necessary part of head and neck cancer pain management, and withholding them here would be a failure of care rather than good stewardship.
What good practice does mean is that opioids are not the only thing offered. Interventional options can reduce the dose needed, and a lower dose means less sedation, less constipation and better function — which is usually what patients actually want.
Interventional options
- Trigeminal nerve blocks for facial and oral pain in a specific branch distribution.
- Sphenopalatine ganglion block for midface, nasal and palatal pain — delivered through the nostril, which matters when the mouth is painful or opening is limited.
- Stellate ganglion block where there is a sympathetically maintained component.
- Occipital nerve blocks for posterior head and neck pain after dissection or radiation.
All of these are placed under ultrasound or fluoroscopic guidance, which matters more than usual here: surgery and radiation distort the anatomy, so landmarks that were reliable before treatment are no longer where they should be.
We work alongside your oncology team
This is a pain service, not a cancer service. We do not direct your cancer treatment and we do not replace your oncologist. We take on the pain so that the rest of the team can get on with treating the disease.