Conditions: Facial Pain

Facial pain

Facial pain is one of the most common reasons people seek medical or dental care. It can arise from many different structures in the face and head, including nerves, sinuses, teeth, jaw joints, blood vessels, skin, and glands, and it can range from a brief electric-like jolt to a constant dull ache. Because so many structures share the same nerve supply, different conditions can feel surprisingly similar. Causes include sinusitis, various headache syndromes (such as migraine and cluster headache), nerve-related conditions (such as trigeminal neuralgia), dental problems, jaw joint problems (temporomandibular disorders), giant cell arteritis, infections, trauma, shingles, tumors, and others. Identifying the correct diagnosis generally requires a physician evaluation with history and physical examination, and sometimes imaging (CT, MRI, dental x-rays) and/or nasal endoscopy. This page provides general information and is not a substitute for a personal evaluation by a clinician; see the site disclaimer.

How facial sensation and pain work: the trigeminal nerve

Most sensation in the skin and bones of the face, and much of the sensation within the mouth and nose, is carried by the trigeminal nerve, also called the fifth cranial nerve. It is the largest of the nerves that come directly from the brain, and it carries both facial sensation and the signals for the muscles used in chewing. A trigeminal nerve serves each side of the face, and each has three branches:

• Ophthalmic branch (V1): the forehead, upper eyelid, eye, and parts of the nose.

• Maxillary branch (V2): the cheek, lower eyelid, side of the nose, upper lip, upper teeth and gums, and the sinuses.

• Mandibular branch (V3): the lower jaw, lower teeth and gums, part of the ear, the lower lip, and the jaw-closing muscles.

The three branches join at a relay station called the trigeminal ganglion and then carry signals into the brainstem, which passes them on to the parts of the brain that register pain. Because structures that share a branch also share these pathways, pain from one structure can be felt in another. For example, a problem in an upper tooth or a sinus may be felt across the cheek. The trigeminal nerve also carries pain signals from the coverings of the brain and its blood vessels, which is part of why headaches and facial pain are so closely related. The layout of the nose and sinuses is described on the page about the anatomy of the nose and sinuses.

How facial pain is evaluated

In many cases, a careful history and physical examination point toward a likely cause. Tests and imaging are generally added when the picture is unclear or a specific problem is suspected.

• History: The history is often the most important step. Clinicians ask where the pain is, what it feels like (sharp, burning, aching, throbbing), how long attacks last, what triggers or relieves it, and whether other features are present, such as tearing, a runny nose, jaw stiffness, rash, fever, or vision changes. The pattern of these details often distinguishes one cause from another.

• Examination: The face, mouth, teeth, jaw joints, sinuses, eyes, skin, and scalp arteries are examined. A brief neurological check tests facial sensation and the chewing muscles.

• Nasal endoscopy: A thin camera passed into the nose allows an ear, nose, and throat specialist to look directly at the sinus drainage areas when a sinus cause is suspected.

• CT scan: Computed tomography gives detailed pictures of bone and the sinuses and is useful for sinus disease, injuries, and dental structures.

• MRI: Magnetic resonance imaging shows nerves, soft tissue, and the brain in detail. It is the preferred test when a nerve problem, mass, or tumor is a concern and is often used when the cause of facial pain remains unclear.

• Dental imaging: Because teeth are a very common source of facial pain, dental x-rays and specialized dental scans are often the first images obtained when a tooth is suspected.

• Blood tests: These are used in specific situations, for example inflammatory markers when giant cell arteritis (see below) is a concern.Facial pain

The skin and bones of the face and much of the sensation within the mouth and nose provide sensory feedback to the brain through the left and right trigeminal nerves. Determining the cause of the facial pain is essential for treating it effectively. Causes of facial pain are many, including sinusitis, various headache syndromes (such as trigeminal neuralgia, cluster headache, migraine), dental problems, jaw joint problems (temporomandibular disorders), giant cell arteritis, trauma, dermatologic conditions, and others. Making the correct diagnosis requires a physician evaluation for history and physical exam and potentially imaging (CT, MRI, dental x-rays) and/or nasal endoscopy.

sinus infection (sinusitis)

Infections in the sinuses frequently account for pain in the face or even elsewhere in the head, such as pain at the top of the scalp. The sinuses are air-filled spaces in the cheekbones, forehead, and around the eyes. When they become inflamed or infected (sinusitis), pressure builds and may cause aching or fullness over the cheeks, around the eyes, or in the forehead, often with nasal congestion, discolored nasal discharge, reduced sense of smell, and sometimes fever. The pain may worsen when leaning forward.

Diagnosis of a sinus infection largely depends on a supportive history that may include sinus or head pain, facial pressure, runny nose, poor sense of smell, and difficulty breathing nasally. If the diagnosis is in doubt, nasal endoscopy or imaging (most commonly a CT scan) may be used to confirm or exclude it.

True “sinus headache” is far less common than many people believe. A large share of pain attributed to the sinuses is actually migraine, which can also cause facial pressure, congestion, and a runny nose. This is one reason a careful history matters, and why “sinus pain” that keeps returning without clear evidence of infection may lead to reconsideration of the diagnosis. Related information is available on the page for conditions of the nose and sinuses.Infections in the sinuses frequently account for pain in the face or even elsewhere in the head, such as pain at the top of the scalp. Correctly diagnosing a sinus infection largely depends on a supportive history that may include sinus or head pain, facial pressure, runny nose, poor sense of smell, and difficulty breathing nasally. If the diagnosis is in doubt, nasal endoscopy or imaging (such as a CT scan most commonly) may be undertaken to confirm or refute this diagnosis.

Neurogenic causes

All pain is transmitted to the brain through nerves, but the term neurogenic pain refers to pain in which the nerves themselves are faulty and wrongfully send pain signals to the brain. Several conditions fall into this group.

• Trigeminal neuralgia: Sudden, severe, electric-shock or stabbing pains on one side of the face, typically in the cheek, jaw, or around the nose, when the facial tissues themselves are healthy. Attacks are brief but can recur many times a day and are often set off by light touch, chewing, talking, brushing teeth, or a breeze on the face. It is the most recognizable and one of the most severe forms of facial nerve pain.

• Persistent idiopathic facial pain: A constant, dull or aching pain that does not fit the pattern of other conditions and for which no structural cause is found on examination or imaging. It may be worsened by touch or by physical and emotional stress. “Idiopathic” means the underlying cause is not known.

• Post-traumatic and post-dental nerve pain: Nerve injury from facial trauma, dental procedures, or surgery can lead to ongoing pain after the tissues have healed and the nerve serving the area remains irritated. It is often a constant burning or aching with flare-ups, usually with changes in sensation such as numbness, heightened sensitivity, or pain from light touch. Related information is available on the page about lingual nerve dysfunction.

• Glossopharyngeal neuralgia: Brief, stabbing pains felt at the back of the tongue, in the throat, or deep in the ear, typically triggered by swallowing, coughing, or yawning. It involves a different nerve than trigeminal neuralgia but causes a similar shock-like quality of pain.

Other infections

Salivary glands, skin, eyes, and eyelids can become painful as a result of infection, and the location of the pain and swelling are helpful in making the diagnosis. Most infections causing facial pain develop fairly rapidly (over a few days) and are associated with redness, swelling, and warmth. The causes include bacteria, viruses, and sometimes fungal organisms.

• Salivary gland infections and stones: Pain and swelling near the jaw or under the tongue, often worse around meals when saliva flow increases. More information is available on the page about conditions of the salivary glands.

• Skin infections: Infections of the facial skin and underlying tissue cause redness, warmth, swelling, and pain, and can become serious if they spread.

• Eye infections and inflammation: Conditions affecting the eye and its surrounding tissues can cause pain around and behind the eye, sometimes with redness and vision changes. Pain together with vision changes is generally regarded as needing prompt attention.

Trauma

Injuries to the face, from falls, blows, sports, or accidents, can fracture facial bones, injure the jaw joint, or damage nerves. Pain from an acute injury is usually clearly linked in time to the event. Some injuries lead to longer-lasting nerve pain even after the tissues have healed.

Dermatologic causes: shingles and postherpetic neuralgia

Shingles (herpes zoster) is a reactivation of the chickenpox virus along a single nerve. When it affects a branch of the trigeminal nerve, it causes burning and stabbing pain in a band on one side of the face, followed by a blistering rash in the same area; tingling and altered sensation are common. In some people, especially older adults, the pain persists for months after the rash heals, a condition called postherpetic neuralgia. Shingles affecting the eye area is of particular concern because it can involve the eye itself. Vaccination substantially lowers the risk of shingles.