The diagnosis and management of patients with facial pain can
be daunting even to experienced physicians. The causes are myriad,
ranging from the mundane (sinus and dental disease) to the exotic
(short-lasting unilateral neuralgiform headache with conjunctival
injection and tearing, or SUNCT). Misdiagnosis and mismanagement
are common. The goal of this chapter is to discuss some of the more
important causes of facial pain, and to guide proper identification
Simply because pain is felt in the face does not imply that it
necessarily originates in facial structures. As elsewhere in the
body, pain may be local in origin, or referred. The role of the
trigeminovascular system and the spinal trigeminal nucleus as a
point of anatomic and physiologic convergence is discussed in Chapter 19. Suffice it to say that the location of the pain may not be so
important diagnostically as other features.
The approach to the evaluation of facial pain requires careful
attention to detail. In the history, it is essential to obtain an
accurate description of the nature of the pain, or pains, what may
have incited it, and what currently provokes and ameliorates it.
Are there associated phenomena, such as autonomic changes? Past
medical history, including trauma and surgical or dental procedures may
provide essential clues. Is there associated depression or any other
psychiatric problem? What therapies have been tried, and with what
After obtaining a detailed history, a thorough examination is
necessary. In addition to the general physical examination, a thorough
neurologic examination is essential. The examiner looks for signs
of raised intracranial pressure (papilledema, diminished up gaze,
sixth cranial nerve palsies) and cranial nerve dysfunction (particularly
oculosympathetic paresis). The head and neck require careful attention.
Are there trigger points? Is there dental or sinus pathology? Auscultation
for bruits and palpation of the carotid artery are sometimes informative
Lastly, the results of prior diagnostic studies are reviewed,
noting the timing of the studies. Were the appropriate studies performed?
If the situation has changed, perhaps a study should be repeated.
Sometimes a diagnosis may become apparent only after serial clinical
examinations or diagnostic studies, or both.
After a careful history, examination, and review of the data,
a tentative diagnosis may be rendered. Often further consultation
is required. Treatment is offered based on the tentative diagnosis and
may, in itself, sometimes be diagnostic. The thoughtful physician
should always be willing to reconsider the diagnosis.
Facial pain clearly represents a diagnostic challenge. With attention
to the fundamental approach outlined in the preceding paragraphs,
the vast majority of patients may achieve a satisfying outcome.
Neuralgias are paroxysmal pain in the distribution of a particular
nerve. The pain is typically maximal at onset and lancinating, and
may be described as “electric shocks” or “jabbing.” There
may be a single sharp pain, or repetitive pains in succession. The
pain may be so brief ...