Case:  36yo RH man who presents with 24 year history of left facial pain starting in the mandible and extending to his temple. He also noted that he had wasting away of the left side of his face since then and progressed to include scalp alopecia. It stabilized in his 20s but started getting worse since 2012. The pain is sharp, stabbing and electrical. The pain is exacerbated by masticating and light touch.  Has pain over the areas of his scalp with hair loss. The pain is severe enough to make him lay down in the dark. He will have these episodes 4-5 times per week. On exam there is notable atrophy of the left side of his face, alopecia on the left and an asymmetric smile. The remainder of his exam is normal. Lab tests are unrevealing. Imaging studies are unremarkable with the exception that his nasal septum is deviated to the left by 4mm.  Prior to our evaluation, the patient was receiving buprenorphine patches for his facial pain and sporadically took gabapentin. After being diagnosed with PRS, the patient was switched to carbamazepine and no longer required use of buprenorphine. He follows with rheumatology and receives weekly methotrexate.