Facial pain

Neurological Causes

Trigeminal neuralgia: Sudden, severe, stabbing pain typically affecting one side of the face along the distribution of the trigeminal nerve
Post-herpetic neuralgia: Persistent burning or aching pain following a herpes zoster infection in the trigeminal distribution
Cluster headache: Severe, unilateral pain around the eye and temple, often with associated autonomic symptoms like lacrimation and nasal congestion
Migraine: Unilateral throbbing pain, often associated with nausea, photophobia, and sometimes aura
Tension-type headache: Dull, bilateral pain often described as a tight band around the forehead and temples
Atypical facial pain: Chronic, poorly localized pain without clear neurological cause, often associated with psychological factors
Glossopharyngeal neuralgia: Sharp, stabbing pain in the throat, tongue, and ear, often triggered by swallowing or talking
Temporomandibular joint (TMJ) disorder: Dull, aching pain around the jaw joint, often associated with clicking or locking of the jaw
Multiple sclerosis: Can present with trigeminal neuralgia, particularly in younger patients

Infectious and Inflammatory Causes

Sinusitis: Dull, aching pain in the face, typically worse on bending forward, often with nasal congestion and purulent discharge
Dental abscess: Severe, throbbing pain localized to a tooth, often with swelling and tenderness of the overlying gum
Herpes zoster (shingles): Burning or itching pain followed by a vesicular rash in the distribution of the trigeminal nerve
Temporal arteritis (giant cell arteritis): Unilateral, throbbing pain in the temple, often with scalp tenderness, jaw claudication, and visual disturbances
Sialadenitis: Pain and swelling in the area of a salivary gland, often with erythema and pus from the duct
Osteomyelitis of the jaw: Persistent, deep pain with swelling, redness, and possibly fistula formation
Rheumatoid arthritis (affecting the TMJ): Dull pain, stiffness, and limited movement of the jaw, often with systemic symptoms
Systemic lupus erythematosus (SLE): Can cause atypical facial pain due to vasculitis or neuropathy
Sarcoidosis: Can cause granulomatous inflammation of the facial nerve, leading to pain and sometimes facial palsy
Sjögren’s syndrome: Dry mouth and eyes with possible parotid gland enlargement and associated pain

Neoplastic and Structural Causes

Tumors of the head and neck: Persistent, progressive pain with possible associated symptoms like swelling, facial asymmetry, or cranial nerve deficits
Parotid gland tumors: Gradual onset pain, often with a mass in the parotid region and possible facial nerve involvement
Nasopharyngeal carcinoma: May cause facial pain, nasal obstruction, epistaxis, and cranial nerve involvement
Pituitary adenoma: Can cause headache and facial pain, often with visual field defects or cranial nerve palsies
Meningioma: May present with gradual onset of pain, often with associated cranial nerve symptoms
Acoustic neuroma: Causes facial pain along with hearing loss, tinnitus, and possible balance issues
Aneurysms: Pain with neurological deficits, depending on the location and size of the aneurysm
Chiari malformation: Occipital headache and neck pain, sometimes with facial pain and neurological symptoms
Arnold-Chiari malformation: May present with occipital headache, facial pain, and other neurological symptoms
Temporomandibular joint disorder: Dull, aching pain in the jaw, often exacerbated by chewing or talking

Symptom Characteristics

Onset and duration: Acute onset may suggest trigeminal neuralgia or dental issues, while chronic pain may indicate sinusitis, TMJ disorders, or neoplasms
Pain type: Sharp or stabbing pain suggests neuralgia, while dull, aching pain is more common in sinusitis or TMJ disorders
Location: Unilateral pain is common in trigeminal neuralgia and cluster headaches, while bilateral pain may suggest tension-type headache or sinusitis
Triggers: Eating, chewing, or temperature changes can exacerbate TMJ disorders or dental pain
Associated symptoms: Rhinorrhea, nasal congestion, or discharge suggest sinusitis; visual disturbances may indicate temporal arteritis or tumors
Response to analgesia: Lack of response may suggest neuropathic pain or more serious underlying pathology
Previous episodes: Recurrent episodes may suggest cluster headaches or trigeminal neuralgia

Background

Past medical history: Consider conditions like migraine, trigeminal neuralgia, sinusitis, and dental problems
Medication history: Use of anticoagulants, antiplatelets, or immunosuppressants, which may complicate or contribute to facial pain
Family history: Look for familial patterns of migraines, neuralgia, or other relevant conditions
Social history: Smoking, alcohol use, and occupation (e.g., exposure to cold or wind) which may exacerbate symptoms
Drug history: Use of recreational drugs, especially those that can cause vasoconstriction or dry mouth
Surgical history: Previous facial surgeries, dental work, or sinus procedures
Psychosocial factors: Consider stress, anxiety, and depression, which can exacerbate or contribute to facial pain
Dental history: Previous dental problems or procedures, which could be the source of referred pain

Laboratory Tests

Full blood count: To assess for infection or inflammation, particularly in sinusitis or temporal arteritis
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Elevated in temporal arteritis and other inflammatory conditions
Autoimmune screen: ANA, RF, and other tests if an autoimmune cause is suspected (e.g., SLE, rheumatoid arthritis)
Thyroid function tests: To rule out hypothyroidism, which can sometimes present with facial pain
Blood glucose: To assess for diabetes, which can contribute to neuropathic pain
Viral serology: If herpes zoster or another viral infection is suspected
Temporal artery biopsy: If temporal arteritis is suspected, based on clinical findings and elevated ESR/CRP

Imaging and Specialist Tests

CT scan of the sinuses: To diagnose or rule out sinusitis, especially in cases of chronic or recurrent pain
MRI of the brain and orbits: Useful in diagnosing intracranial causes of facial pain, including tumors, aneurysms, or multiple sclerosis
Dental X-rays or panoramic radiographs: To assess for dental abscesses, impacted teeth, or other dental causes of facial pain
Ultrasound of the salivary glands: To evaluate for sialadenitis or salivary gland tumors
Electromyography (EMG): May be used to assess for neuropathic pain, particularly in cases of suspected trigeminal neuralgia
Carotid Doppler ultrasound: To assess for carotid artery dissection if suspected based on history and clinical findings
Fluorescein angiography: To assess retinal vasculature in cases where temporal arteritis is suspected

Neurosciences