Facial Pain

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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CauseSymptomsDiagnosisTreatment
DentalDental 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 painMRI 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 neuralgiaSharp ‘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 painExclude 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 syndromeTypically middle-aged menopausal females though not always. Burning sensation to mouth, subjective dry mouth and altered taste (e.g. metallic).Postherpetic neuralgiaTreat underlying cause if found. Otherwise, reassurance that symptoms will improve. Anti-depressants can be trialled.
Postherpetic neuralgiaFollowing 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 arteritisPain 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/nasalIV 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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