Burning Mouth Syndrome as a Central Pain Disorder: A Case Study Demonstrating Response to Occipital Nerve Block Treatment

Background: Burning Mouth Syndrome (BMS) is a chronic orofacial pain condition characterized by a burning sensation in the oral cavity without identifiable lesions. It predominantly affects women (especially postmenopausal) but can occur in men. BMS is considered a multifactorial neuropathic pain disorder involving both peripheral small-fiber neuropathy and central dysregulation, often accompanied by taste alterations (dysgusia) and xerostomia despite normal oral exams. Treatment is challenging, with modest responses to agents like clonazepam, tricyclic antidepressants, or gabapentinoids. Observations: We present a 67-year-old male with recalcitrant primary BMS who showed complete remission temporally associated with occipital nerve blockade, likely affecting central trigeminocervical pathways. Initial therapy with amitriptyline (25 mg) and gabapentin (900 mg/day) yielded ~30% pain relief. Given suspected central sensitization, greater and lesser occipital nerve (GON) blocks were administered in series. After the first, second, and third ON blocks, pain was reduced by ~50%, 80%, and 100%, respectively. Remission persisted at one-year follow-up under continued medications. A mild recurrence (~20% of baseline pain) responded fully to a fourth GON block, maintaining another year of pain-free status. Lessons: This case underscores the complex central mechanisms in BMS and illustrates that modulating central pain circuits via occipital nerve blockade, through trigeminocervical convergence mechanisms, without direct trigeminal intervention. We discuss the diagnostic challenges of BMS, the rationale of occipital neuromodulation, and how this novel therapeutic strategy compares with current literature, supporting the hypothesis of central sensitization in BMS.