Facial Pain Causes, Symptoms, and Treatment

Authored by , Reviewed by Dr Laurence Knott | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Trigeminal Neuralgia article more useful, or one of our other health articles.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Facial pain has a long list of possible causes but the diagnosis can often be made by a good history and examination. The common causes of facial pain are often benign and self-limiting but it is essential not to miss those conditions that require urgent treatment - eg, temporal arteritis, or early diagnosis - eg, malignancy. There is a tendency to overdiagnose bacterial sinusitis when the real cause may be a viral upper respiratory tract infection or, much less frequently, a more serious cause of facial pain.

Facial pain, alone or combined with other symptoms, is a frequent complaint.[5] However idiopathic facial pain syndromes are relatively rare.[6]

History

  • Site:
    • Establish if unilateral or bilateral and whether it relates to a nerve distribution. Unilateral pain occurs in dental conditions, trigeminal neuralgia, salivary gland conditions. Pain may be either bilateral or unilateral in sinus infection, temporomandibular disorders, headaches and giant cell arteritis.
    • Pain in the region of the ear may be referred from the skin, teeth, tonsils, pharynx, larynx or neck.
    • Tenderness over the maxilla may be due to sinusitis, dental abscess or carcinoma.
  • Character:
    • Establish whether it is continuous or episodic and the severity and nature of the pain.
    • Trigeminal neuralgia: intermittent sharp, severe pain in the distribution of the divisions of the trigeminal nerve.
    • Infections of teeth, mastoid and ear: often dull, aching quality.
  • Precipitating factors:
    • Precipitated by food or chewing: dental abscess, salivary gland disorder, temporomandibular joint disorder or jaw claudication due to temporal arteritis.
    • Trigeminal neuralgia: can be precipitated by various factors, including eating, talking and touching or washing the face. Even the slightest touch of the skin can cause intense pain.
  • Associated facial pain symptoms:
    • Obstruction of the lacrimal duct by nasopharyngeal carcinoma may cause watering of the eyes.
    • Otorrhoea and/or hearing loss suggest an ear or mastoid cause.
    • Nasal obstruction and rhinorrhoea may be due to maxillary sinusitis or carcinoma of the maxillary antrum. Carcinoma of the maxillary antrum may also present with unilateral epistaxis.
    • Proximal muscle weakness and pain may be due to polymyalgia rheumatica, associated with temporal arteritis.
    • Intermittent presence of a lump around the jaw may suggest salivary duct obstruction.
  • Impact of pain: effect on mood, sleep, eating and quality of life.

Examination

  • Unilateral erythema and vesicles in the distribution of the trigeminal nerve: herpes zoster infection (may not be present in the early stages of the disease).
  • Localised erythema or swelling: localised infection or carcinoma.
  • Inspection of the nose and throat may demonstrate a nasopharyngeal tumour.
  • Intraoral inspection may reveal any obvious pathology but may require dental expertise.
  • Examine the cranial nerves.
  • Facial palsy: may be due to a tumour of the parotid gland.
  • Tenderness of the superficial temporal artery associated with temporal arteritis.
  • Tenderness over one or more sinuses may indicate sinus infection.
  • Cervical lymphadenopathy: infection or carcinoma.
  • Lumps over the parotid area may indicate salivary gland tumours or blockage of the gland (whether the lump is intermittently present or continuously so is helpful).
  • Pain or crepitus on movement of the jaw may indicate temporomandibular joint dysfunction.

Further investigation will be guided by the results of findings on history and examination.

  • FBC: raised white cell count in infection or malignancy.
  • ESR, CRP: increase in infection, malignancy, temporal arteritis.
  • X-rays:
    • Dental x-rays can be carried out by community dentists where there is suspected dental pathology.
    • Opacification of the sinus and destruction of bone with carcinoma of sinuses.
    • Opacification may also occur in sinusitis.
    • Mastoid films may show opacification in cases of mastoiditis.
  • Ultrasound scans are useful as first-line investigation for suspected salivary gland pathology.
  • MRI or CT scans may be necessary for some conditions.
  • Sialography: parotid conditions - eg, duct stones, sialectasis.
  • Fine-needle aspiration: parotid tumours.
  • The essential aspect of management in primary care is to make an accurate diagnosis. The management will then depend on the identified cause of facial pain.
  • The first-line treatment for atypical facial pain is a tricyclic antidepressant such as amitriptyline. Fluoxetine and venlafaxine can also been considered.[8]
  • Cognitive behavioural therapy (CBT) may be combined with antidepressant treatment.[1]
  • With advancing techniques and technology, neurostimulation can be promising in treating intractable pain of the head and face.[9]
  • Specialist referral (usually to a maxillofacial clinic, unless clinical findings suggest a diagnosis where ENT/community dentistry/neurology/rheumatology referral may be more appropriate) should be made according to local guidelines. One such guideline suggests referring patients who have:[10]
    • Facial pain persisting for more than three months.
    • Persistent temporomandibular disorders not responding to simple analgesics, lifestyle changes and reassurance.
    • Persisting pain affecting function and causing distress.
    • Widespread pain.
    • Pain which is part of systemic disease.
    • Significant psychological or social problems.
    • Co-existing mental health problems which have an impact on treatment.
    • Compliance problems - eg, side-effects.
    • A recognised pain syndrome such as trigeminal neuralgia.
    • Patients with special needs - eg, learning disabled, communication problems.

Further reading and references

  • Aggarwal VR, Macfarlane GJ, Farragher TM, et al; Risk factors for onset of chronic oro-facial pain--results of the North Cheshire oro-facial pain prospective population study. Pain. 2010 May149(2):354-9. Epub 2010 Mar 20.

  • Forssell H, Jaaskelainen S, List T, et al; An update on pathophysiological mechanisms related to idiopathic oro-facial pain conditions with implications for management. J Oral Rehabil. 2015 Apr42(4):300-22. doi: 10.1111/joor.12256. Epub 2014 Dec 8.

  1. Zakrzewska JM; Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013 Jul111(1):95-104. doi: 10.1093/bja/aet125.

  2. Gerwin R; Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis. Int J Environ Res Public Health. 2020 Sep 2517(19). pii: ijerph17197012. doi: 10.3390/ijerph17197012.

  3. De Corso E, Kar M, Cantone E, et al; Facial pain: sinus or not? Acta Otorhinolaryngol Ital. 2018 Dec38(6):485-496. doi: 10.14639/0392-100X-1721.

  4. Ruffatti S, Zanchin G, Maggioni F; A case of intractable facial pain secondary to metastatic lung cancer. Neurol Sci. 2008 Apr29(2):117-9. Epub 2008 May 16.

  5. Van Deun L, de Witte M, Goessens T, et al; Facial Pain: A Comprehensive Review and Proposal for a Pragmatic Diagnostic Approach. Eur Neurol. 202083(1):5-16. doi: 10.1159/000505727. Epub 2020 Mar 27.

  6. Ziegeler C, Beikler T, Gosau M, et al; Idiopathic Facial Pain Syndromes-An Overview and Clinical Implications. Dtsch Arztebl Int. 2021 Feb 12118(6):81-87. doi: 10.3238/arztebl.m2021.0006.

  7. Trigeminal neuralgia; NICE CKS, January 2018 (UK access only)

  8. Cornelissen P, van Kleef M, Mekhail N, et al; Evidence-based interventional pain medicine according to clinical diagnoses. 3. Persistent idiopathic facial pain. Pain Pract. 2009 Nov-Dec9(6):443-8.

  9. Antony AB, Mazzola AJ, Dhaliwal GS, et al; Neurostimulation for the Treatment of Chronic Head and Facial Pain: A Literature Review. Pain Physician. 2019 Sep22(5):447-477.

  10. How to refer - Facial pain; University College London Hospitals

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