NHS Tayside RefGuide
The head and neck is a complex anatomical and sensory region. It is often the case that we try to associate an organic process to head and neck pain, in many cases the facial pain is a type of primary headache and careful history is needed to prevent these patients being labelled with a disease process they don’t have. Their symptoms often go on for years and are compounded by the emotional and psychological component that is associated with chronic pain.
Primary headaches include:
- Migraine with or without aura - Commonly one half of the head, +/- nausea, photo or phonophobia, improves with rest, often a previous history of migraine
- Tension headache - Diffuse band around the head, non-pulsatile,
- Mid-segmental facial pain – Bi-lateral constant pain of the eye/nose, similar characteristics to tension type
- Trigeminal autonomic cephalgias – Cluster headache is an example, short lived severe pain, can occur up to 8 times a day, debilitating.
There are many causes of secondary headache and facial pain. Patients are often labelled with “sinus” pain but in our experience and a departmental audit, >95% of patients presenting with facial pain had no nasal or sinus disease. In the absence of nasal symptoms, non nasal causes are most likely. If there are nasal symptoms, treatment of these should improve the symptoms.
Other causes of facial pain that aren’t headache include TMJ disorders as well as fibromyalgia and other chronic pain conditions. TMJ disorders can affect 1 in 10 people and more frequently in women, pain is centred around the head of the mandible anterior to the tragus. In the majority of cases this will settle with time and a modified soft diet for a short period.
Red flag symptoms
- Persistent progressive unilateral pain, unilateral nasal bleeding or block, paraesthesthia over the cheek, change in the external shape of the nose/cheek, change in vision or dentition
Primary care management
- Rule out other primary cause of headache, the majority are migraines therefore it is worth trialling avoidance of triggers and preventative medication.
- Try to get patients to avoid regular dependence on analgesics as they can worsen some headaches.
- Avoidance of regular nasal decongestants as this can exacerbate nasal symptoms.
- Manage the nasal symptoms if you suspect a sinogenic cause with saline rinses and a topical steroid spray, if any allergic symptoms then add in an anti histamine either systemically or topically.