Facial pain referrals to neurology

This Fact Sheet provides information on how to treat patients with facial pain with different symptoms, situations and circumstances.

Please note this fact sheet is only designed as a brief summary of management.

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

Migraine

Facial pain is common as part of acute migraine.

Oral / dental structures / salivary glands

This is usually intra-oral pain, occasionally facial pain.

Persistent idiopathic facial pain (previously “atypical facial pain”)

Usually constant unilateral pain and resistant to all medication. Similar patient profile to fibromyalgia and other chronic pain syndromes.

Sinusitis

Over diagnosed from a neurology perspective (usually migraine or persistent idiopathic facial pain). ENT state that sinusitis always includes one of nasal blockage, nasal congestion or nasal discharge.

Temporal arteritis

A rare but important cause of facial pain, usually in people >70 and rare in <60 years. Have a low threshold for checking ESR (usually >50) or CRP (>5). If suspected refer urgently to neurology.

Temporomandibular joint disorders (TMJ)

This is usually associated with jaw movement.

Trigeminal neuralgia

Trigeminal neuralgia is the most common of the craniofacial neuralgias; characteristic history, 70% are over 60 years 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.

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.

Facial pain not fitting with above descriptions

Treatment: If mild, consider tricyclic prior to referral

Migraine

Treatment: As per headache pathway

When to refer to neurology: Treatment resistant migraine only (3 preventative agents >3 months and appropriate acute treatment (see RefHelp guidance on Migraine).

Persistent idiopathic facial pain (previously “atypical facial pain”)

Treatment: Tricyclics, e.g. amitriptyline, nortriptyline

When to refer to neurology: If no focal neurological symptoms or signs then suggest referral to pain service.

Sinusitis / TMJ / oral

Referral to Ear Nose and Throat (ENT) / maxillofacial / oral surgery

Temporal arteritis

Refer to on call neurology service if typical story and ESR and CRP high

Trigeminal neuralgia

Treatment:

• Carbamazepine or oxcarbazepine are the drugs of choice
• Second line agents (with poor evidence base) include lamotrigine, gabapentin, pregabalin, baclofen, phenytoin
• Invasive therapies: microvascular decompression or ablative procedures

When to refer to neurology: 

• If not responding to medication then patient may be suitable for surgical treatment (refer to neurosurgery)
• If not suitable for neurosurgery or diagnostic uncertainty refer to neurology

Lambru G, Zakrzewska J, Matharu M. Trigeminal neuralgia: a practical guide. Practical Neurology 2021;21:392-402. DOI: 10.1136/practneurol-2020-002782 

Siccoli MM, Bassetti CL, Sándor PS. Facial pain: clinical differential diagnosis. Lancet Neurol. 2006 Mar;5(3):257-67. DOI: 10.1016/S1474-4422(06)70375-1