Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus (VZV), which remains dormant in cranial and spinal root nerves after the initial chicken pox infection. The prodromal period of dermatomal pain before vesicle eruption, described as a burning, itching or shooting sensation, is clinically significant. Its mean duration is about 5 days and the mean severity of pain is about 6 on a VAS scale of 0 to 10. The prodrome of HZ may be severe and prolonged in
aged or immunosuppressed patients. Herein, we present an 88 year old man had prodromal facial pain for 3 months before the appearance of typical herpes zoster vesicles. He was initially seen by a dentist, an ENT doctor, a neurologist, and a pain physician. Physical examination and diagnostic tests during this period, including brain MRI and MRA, did not identify a definitive cause of the pain, and he received an initial diagnosis of tension type headache with temporomandibular joint syndrome and sternocleidomastoid myofascial pain. Eruption of vesicles in the right ear duct then appeared, and he was diagnosed with herpes zoster oticus,
and was successfully treated with acyclovir and prednisone. The case suggest that HZ should be considered in aged or immunosuppressed patients after exclusion the other differential diagnosis and pain treatment with pregabalin attempted if other treatments have limited efficacy in reducing neuralgia, even without a concurrent  skin rash. 

Herpes zoster, Pain, Neuralgia, Elderly.