Facial pain can be disabling and affects millions of Americans. Common causes of facial pain include dental problems (tooth abscess), sinusitis, trigeminal neuralgia, temporomandibular (TMJ) joint dysfunction, cluster headache and migraine headache.
Signs and symptoms
Facial pain accompanied by chest, shoulder, neck or arm pain may be indicative of a heart attack. Acute sinusitis may present as a viral upper respiratory infection that persists longer than expected, or unilateral or bilateral tenderness under the eyes, fever, or a dull headache.
Trigeminal neuralgia is characterized by intense facial pain that last from a few seconds to several minutes or hours. The attacks are described as stabbing electric shocks, burning, exploding or shooting pain. Symptoms of TMJ dysfunction include headache, facial pain, grinding or popping sounds on jaw movement, ear fullness and tinnitus.
Cluster headaches are experienced as repeated attacks of excruciatingly severe unilateral headache pain associated with autonomic features such as tearing of the eyes, runny nose, conjunctival redness, eyelid drooping or sweating on one side of the face. Migraine headaches are characterized by throbbing pain on one side of the head, pain behind the eye, nausea, vomiting and light sensitivity and may be preceded by an “aura” (flashing lights, zigzag patterns).
Clinical suspicion will dictate the workup of facial pain. If facial pain co-occurs with chest, shoulder or arm pain, an urgent 12-lead electrocardiogram can identify myocardial ischemia. If sinusitis is suspected, sinus x-rays may reveal mucosal thickening or complete opacification of the sinus. Purulent post-nasal mucus may be seen in the oropharynx.
A diagnosis of trigeminal neuralgia is based primarily on clinical symptoms. A magnetic resonance imaging (MRI) study can determine if the cause of the trigeminal neuralgia is multiple sclerosis. TMJ dysfunction is suspected when there are grating, popping and clicking noises on jaw movement with locking or limited opening of the jaw. Cluster headaches and migraines are diagnosed on clinical grounds.
There are some treatments that help with diagnosis. If trigeminal neuralgia is suspected, an injection of numbing medicine around the nerve can help confirm the diagnosis and provide pain relief at the same time.
Suspected myocardial infarction is treated with aspirin, nitroglycerin, beta-blockers and either thrombolytic agents or percutaneous coronary intervention (angioplasty or arterial bypass surgery). Sinusitis is treated with antibiotics, decongestants and mucolytic agents.
Carbamazepine is considered first-line therapy for trigeminal neuralgia along with NSAIDS and possibly neurogenic medications like Lyrica or Neurontin. Additional treatment for TMJ may include a sphenopalatine ganglion block and possibly a glycerine injection at the base of the trigeminal nerve. If these treatments prove to be beneficial, a radiofrequency ablation may be indicated of the nerve. That can provide over 6 months of potential pain relief and simply be repeated when necessary.
Pain due to TMJ dysfunction may be responsive to nonsteroidal anti-inflammatory drugs (NSAIDs) and a soft diet. If these measures fail, a plastic guard that fits over the upper and lower teeth can reduce teeth clenching at night. An intra-articular cortisone injection may be beneficial.
Cluster headaches respond to brief inhalation of 100% oxygen, injectable forms of triptans (Imitrex), injectable somatostatin, intranasal local anesthetics and intravenous dihydroergotamine. Migraine headaches respond to injectable, sublingual or intranasal triptans or ergotamine.