Facial pain - neurology

What are the common causes of facial pain?

Like headache, facial pain diagnoses are fundamentally based on history. Common causes are

• Persistent idiopathic facial pain (previously “atypical facial pain”). Usually, constant unilateral and resistant to all medication. Similar patient profile to fibromyalgia and other chronic pain syndromes.
• Migraine: facial pain is common as part of acute migraine
• Trigeminal Neuralgia. Trigeminal neuralgia is the most common of the craniofacial neuralgias; characteristic history, 70% are over 60 yrs old, almost always unilateral (bilateral with alternating unilaterality very rare), typically V2 and V3 (cheek and jaw). Lancinating, stabbing, jolts of pain usually lasting seconds. Pain is spontaneous or triggered by simple stimuli such as touching, teeth brushing, talking/chewing. About half have underlying persistent facial pain.
• Sinusitis: over diagnosed from a neurology perspective (usually migraine or persistent idiopathic facial pain). ENT advise that sinusitis ALWAYS includes one of nasal blockage, nasal congestion or nasal discharge.
• Temporomandibular joint disorders (TMJ): usually associated with jaw movement
• Oral/Dental structures/Salivary glands; usually intra-oral pain, occasionally facial pain
• Temporal Arteritis. A rare but important cause of facial pain. Usually in people >70 and rare in <60 yrs. Have a low threshold for checking ESR (usually >50) or CRP (>5). If suspected refer urgently to Rheumatology

When should I request CT head? 

CT head in persistent idiopathic facial pain or migraine is not usually indicated.

For trigeminal neuralgia it may be reasonable to refer for assessment and subsequent MRI, if you think the patient may be a candidate for surgical treatment. If they are not and there are no other focal neurological symptoms or signs then reasonable to manage in primary care.