Facial Pain, Causes, Symptoms and Treatment

Facial pain causes, symptoms and treatment
Facial pain can be caused by number of different entities, which has to do with the different disorders affecting the underlying or nearby structures of the face. The causes can vary from common and benign conditions to serious entities.

Causes
Below are some of the most common causes leading to facial pain;

Disorders involving the mouth structures
oral sores, oral infection, tooth abscess, large cavity, cracked tooth or nasopharyngeal carcinoma.

Disorders involving the paranasal sinuses
Sinusitis due to infection, sinuses large mucocele, sinuses carcinoma, large osteoma. osteitis, Usually maxillary sinuses are affected leading to pain over the one or both sides of the cheeks. In this case, there is tenderness over the maxillary sinuses on palpation or percussion.

Parotid gland disorders
Parotid duct obstruction leading to large swelling over the parotid gland however this swelling is fluctuating and intermittent
Parotid gland inflammation or infection like mumps or parotid gland abscess
Parotid gland tumour
Salivary duct or parotid gland calculi

Eye problems
Corneal abrasion, glaucoma or eye infection ie cellulitis

Ear problems
Otitis media, otitis externa, nasopharyngeal carcinoma leading to referred pain to the ear and face.

Temporomandibular joint dysfunction (TMJ)
Pain is felt in the temporomandibular joint area and also of the face during chewing or opening and closing the jaw.

Herpes zoster infection affecting the trigeminal nerve(shingles)
Herpes zoster virus is the same virus of measles which resides in the nerve root ganglia and when in older age immune system goes down, it recurs in the form of herpes zoster attacks. These attacks occur in patients who’ve had developed measles during childhood. Pain is felt on one side of the face and can be intense, blisters are noticed on the face in the distribution of the trigeminal nerve, usually the ophthalmic or maxillary divisions of the trigeminal nerve are involved leading to pain over the forehead or maxillary area which can be very severe pain

Postherpetic neuralgia
After herpes zoster infection has subsided, patient can develop severe degree of constant pain over the face, which can linger on for months or years

Trigeminal neuralgia
Trigeminal nerve supplies sensations to the ipsilateral face, eye, oral cavity, sinuses , teeth and muscles of mastication.
It has 3 divisions, ophthalmic, maxillary and mandibular. Ophthalmic division supply sensation to the eye and forehead area, maxillary division supplies the area over the middle portion of the face, maxillary sinuses and teeth in the maxilla.
Mandibular division supplies the sensation over the mandible and lower teeth and oral mucosa and also supplies the strength to the muscles of mastication.

In this case, trigeminal nerve gets irritated in the cranial cavity after its exit from the brainstem by the tiny blood vessels crossing the nerve or the gasserian ganglion. Patient experiences very severe degree of intense sharp shooting pains over the face mostly in the distribution of the ophthalmic or maxillary divisions of the trigeminal nerve. These attacks only last for a few seconds each time but this pain is one of the worst pain a person can experience. Pain attacks might occur hundreds of times a day and brought on by touching or washing the face, brushing the teeth or speaking or swallowing or during eating.

Temporal arteritis( giant cell arteritis)
This is a serious condition which needs to be treated right away otherwise the patient can lose vision in the eye. Temporal arteries over the scalp over the temple get swollen and inflamed and are tender to touch and sometimes this pain can also radiate to the face although it is usually localized to the temporal head area. This condition is more common in older people, sedimentation rate and CRP are elevated, on examination, there is lack of pulses in the temporal arteries and sometimes nodules can be felt on palpation and there is a lot of tenderness on palpating the arteries. This condition is treated with corticosteroids. Biopsy of bilateral temporal arteries is required to confirm the diagnosis. At times, it is accompanied by polymyalgia rheumatica in which patient experiences severe degree of pain and stiffness of the proximal muscles of the arms and legs. Stiffness and pain is most prominent in the morning after rest which gets somewhat better with activity.

Facial Migraine
In facial migraine, the pain is mostly felt over the face rather than the head and is accompanied by the usual symptoms of migraine headache which include photophobia, intolerance to loud noise, and nausea. Sometimes, facial pain can be the only manifestation of a migraine headache without any other associated symptoms. These attacks are diagnosed because of the occurrence of these facial pains periodically and pain free intervals between the attacks.

Cluster headaches
They are usually located around or behind the eye. Attacks last from 45 minutes to 2 hours, during which there is redness of the eye, tearing from the eye and running nose. Usually there is also drooping of the upper eyelid and swelling of the eye during the attacks. sometimes the pain can be felt over the face along with the eye. These attacks come in clusters and they can last for weeks or months and then remit for many months or years. When patient is suffering from cluster headache attack, these attacks can occur anywhere from one to several attacks in 24 hours. Sometimes, patient experiences pain during the night at the same time of the night on daily basis like a clock work.

Atypical facial pain
This type of pain usually occur in patients who suffers from severe depression and pain is unremitting and chronic in nature and can be debilitating. Repeated investigations like blood workup, CT scan or MRI scans fail to reveal any underlying cause. Treatment of atypical facial pain is with use of antidepressants and psychological counseling.

Angina pectoris
Sometimes angina pectoris can present with neck and facial pain on left side radiating down the left arm, it is an emergency because of impending heart attack requiring immediate medical attention

Aortic arch dissection
Pain can radiate up from chest to the neck and facial area and is abrupt in onset.

Carotid artery dissection
Carotid artery dissection can lead to ipsilateral neck and facial pain and is abrupt in onset

Carotidynia
In this condition, pain is felt over the carotid artery radiating upwards towards the mandible or face, the pain is made worse on palpation over the carotid artery, treatment is with NSAIDs.

Investigations
Investigations are done based upon the history and clinical examination findings and suspicion of a particular underlying disorder.

X-rays of the sinuses,TMJ and dental x-rays
They help to rule out the possibility of underlying sinusitis, temporomandibular joint dysfunction or dental disease which might be leading to the facial pain.

Dental and oral examination by a dentist oral surgeon
It is helpful to rule out any underlying dental disease like tooth abscess, cracked tooth, pulpitis, oral infections or carcinoma, TMJ problem.

ENT examination
It is helpful to rule out the possibility of ear infection, nose conditions, parotid gland tumor or parotid duct obstruction due to calculi and nasopharyngeal carcinoma or mastoiditis.

Sedimentation rate and C-reactive protein
If temporal arteritis is suspected, then sedimentation rate and CRP are ordered and usually they are elevated, if clinical findings are consistent with temporal arteritis and these tests are abnormal, patient is started on steroids right away and arrangements are made to have temporal artery biopsy for confirmation of the diagnosis because if there is a delay in the treatment, there is danger of loss of vision due to involvement of the ophthalmic artery by temporal arteritis.

MRI scan of the brain with auditory canals examination
If the patient suffers from trigeminal neuralgia, then MRI scan of the brain is helpful to rule out any compressive lesion like acoustic neuroma in the cerebello-pontine angle which might be affecting the trigeminal nerve and leading to neuralgia.

Sialography
It helps to rule out the possibility of salivary gland obstruction by calculi

Parotid gland needle biopsy or aspiration
If parotid gland tumor or other pathologic process is suspected then this test is done

Treatment
Treatment depends upon the underlying cause leading to the facial pain.

Treatment by an oral surgeon or dentist
If the pain is stemming from oral conditions or teeth or TMJ dysfunction. Patient might need treatment with antibiotics, root canal therapy, extraction of the tooth, biopsy of a suspicious lesion, mouth guard use, TMJ surgery etc.

Treatment by an ENT specialist
If the cause is paranasal sinusitis, nasopharyngeal carcinoma, mastoiditis, ear infections, parotid gland disorders or nasal disorder

Treatment by a neurologist
For trigeminal neuralgia, shingles, postherpetic neuralgia, migraine headaches, cluster headaches, atypical facial migraine, atypical facial pain, temporal arteritis.

For trigeminal neuralgia;
Following medications usually used singly or in combination
Gabapentin
Tegretol
Lyrica
Dilantin
Keppra
Baclofen
Klonopin
Zanaflex

For herpes zoster
Acyclovir or other antiviral medications
Prednisone
For postherpetic neuralgia
Gabapentin
Lyrica
Amitriptyline
Nortriptyline
Sometimes combination of gabapentin with amitriptyline or nortriptyline is used for control of pain.

For facial migraine attacks
If these attacks occur very frequently than preventive medication is helpful to control these attacks. Following medications are commonly used.
Preventive Therapy
Topamax
Depakote
Propranolol
Keppra
Lamotrigine

Abortive therapy
This is used at the onset of the migraine headache episode and it can lessen the duration and intensity of the headache however, it needs to be used right in the beginning of the warning signs of impending headache.
Imitrex
Relpax
Maxalt
Amerge
Midrin-it is an older medication which also works pretty well but it is not easily available now because of the newer medications in the market

For cluster headaches
Same medications as described above for migraine are commonly used

For temporal arteritis
It is treated with corticosteroids, mostly prednisone is started at dosage of 60-80 mg daily for many months and then the dosage is slowly decreased depending upon the sedimentation rate results and clinical stabilization. Most of the patients require use of prednisone for years to keep the arteritis under control.

For atypical facial pain
Patient is treated with antidepressants which include
Amitriptyline
Nortriptyline
Citalopram
Sertraline
Effexor
Depakote
Lithium carbonate

In addition, patient requires psychological counseling by a therapist to help deal with underlying depression.

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About the Author

Javaid Iqbal, MD

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