Facial pain is common, and it can be not easy to form a certain diagnosis. In this article, we will provide a differential for the causes of facial pain and key features to consider. These rely on a thorough pain history, followed by examination and investigations as necessary. If the cause of pain is unclear or there are any red flag symptoms a referral must be made to the appropriate specialty. This list is not exhaustive and types of headaches are covered elsewhere, but it covers the most common causes of facial pain.
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Cause | Symptoms | Diagnosis | Treatment |
Dental | Dental pain, often located to a specific tooth or teeth. Worse when eating or drinking hot, cold or sweet. | Clinical diagnosis and needs referral to a dentist. They will then carry out necessary investigations. | Treated by dentist depending on cause of pain. |
TMJ disorders/musculoskeletal pain | MRI is needed to rule out a space-occupying lesion or MS. | Clinical diagnosis. Can have imaging if underlying pathology is suspected. | Depending on cause of pain. Often needs psychosocial support and may need referral to a dentist for a mouth guard if grinding their teeth. If symptoms do not resolve with simple measures or there is a complex history, the patient should be referred to OMFS. |
Trigeminal neuralgia | Sharp ‘lightning’ or ‘shooting’ severe pain localised to one of the divisions of the trigeminal nerve. Typically lasts for a few seconds and does not cross the midline. | Immediate management can include infiltration with local anaesthesia and analgesia. Long-term management includes medical (carbamazepine) or surgery if a cause is found (decompression). | Immediate management can include infiltration with local anaesthesia and analgesia. Long term management includes medical (carbamazepine) or surgery if a cause is found (decompression). |
Atypical facial pain | Exclude underlying nutritional deficiencies (iron, B12, folate, zinc), candida and diabetes. | Diagnosis of exclusion. Investigations may be needed to rule out other causes. | Psychological support if needed and reassurance. Anti-depressants can be trialled. |
Burning mouth syndrome | Typically middle-aged menopausal females though not always. Burning sensation to mouth, subjective dry mouth and altered taste (e.g. metallic). | Postherpetic neuralgia | Treat underlying cause if found. Otherwise, reassurance that symptoms will improve. Anti-depressants can be trialled. |
Postherpetic neuralgia | Following singles infection. Neuropathic pain localised to a division of the trigeminal nerve. | Clinical diagnosis. | Neuropathic agents (gabapentin or pregabalin) can be used. Other medications include antidepressants (amitriptyline) and anticonvulsants (carbamazepine). This pain is very difficult to manage. |
Temporal arteritis | Pain in the temporal region, normally in those >50 years old. Temporal tenderness and may have visual changes. | Elevated ESR but treated on clinical suspicion due to risk of eye complications. Temporal artery biopsy. | IV or oral steroids dependant on symptoms. |
Sinus/nasal | IV or oral steroids depending on symptoms. | Clinical diagnosis. CT sinuses can be done if ongoing symptoms or diagnosis is unclear. | Analgesia and decongestants. |
References
Payne, K.F., Goodson, A.M., Tahim, A.S., Ahmed, N. and Fan, K.F., 2015. On-call in Oral and Maxillofacial Surgery. Libri Publishing.
Isaac, R., Goodson, A.M., Payne, K.F., Tahim, A.S. and Brennan, P.A., 2022. Oral and Maxillofacial Surgery: An Illustrated Guide for Medical Students and Allied Healthcare Professionals. Libri Publishing.
Written by Dr Janhvi Shah BDS (hons) MBBS MFDS (RCSEd) PgCert MedEd
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