Diagnosis & Management of Facial Pain

Key Concept First

A. SINOGENIC FACIAL PAIN

• Pressure/fullness/throbbing over paranasal sinuses
• Purulent nasal discharge + fever (acute sinusitis)
• Unilateral pain when a specific sinus is involved (e.g., sphenoid mucocele, pyomucocele)

• Nasal endoscopy - look for purulent discharge, mucosal disease
• CT paranasal sinuses (note: 1/3 of normal people have incidental mucosal changes on CT - do not over-interpret)
• Symptoms + fever + purulent discharge = rhinogenic cause likely

• Treat underlying sinusitis (antibiotics, nasal steroids, saline)
• ESS (Endoscopic Sinus Surgery) only if clear rhinogenic cause + failure of medical treatment
• Surgery for headache/pain alone = controversial; must rule out neurological cause first

B. NON-SINOGENIC FACIAL PAIN

1. Migraine

• Recurrent, often unilateral, moderate-to-severe, throbbing/pulsatile headache
• Associated: nausea, vomiting, photophobia, phonophobia
• May have aura (visual disturbance before headache)
• Rx: Acute = triptans (sumatriptan), NSAIDs; Prophylaxis = propranolol, amitriptyline, topiramate

2. Tension-Type Headache

• Bilateral, non-pulsatile, "vice-like/pressure" sensation
• Involves forehead, temporoparietal area, occiput
• Often associated with stress, anxiety, depression
• Skin hyperaesthesia can mimic sinusitis
• Rx: Amitriptyline (start 10 mg ON, increase by 10 mg every 6 weeks, max ~50 mg); relaxation therapy, stress management

3. Cluster Headache (Trigeminal Autonomic Cephalalgias)

• Severe, strictly unilateral orbital/periorbital pain
• Lasts 15 min to 3 hours; occurs in "clusters" (daily attacks for weeks)
• Autonomic features: lacrimation, rhinorrhoea, ptosis, miosis, conjunctival injection
• Rx: Acute = 100% O2 inhalation, sumatriptan injection; Prevention = verapamil, lithium

4. Trigeminal Neuralgia

• Paroxysmal, severe, lancinating/stabbing pain along trigeminal nerve distribution
• Trigger zones on face (touch, air currents, eating, talking can trigger)
• Unilateral; lasts seconds to minutes; can repeat hundreds of times/day
• Cause: vascular compression of trigeminal nerve root (usually superior cerebellar artery)
• Investigations: MRI brain (to exclude MS, posterior fossa lesion)
• Rx:
  • 1st line: Carbamazepine
  • 2nd line: Gabapentin, Lamotrigine, Topiramate
  • Surgery: Microvascular decompression (MVD) - best long-term; Percutaneous rhizotomy; Stereotactic radiosurgery (Gamma knife)

5. Post-Herpetic Neuralgia

• Pain persisting after herpes zoster (shingles) at the rash site
• Up to 50% of elderly patients develop it
• Rx: Carbamazepine, Gabapentin +/- tricyclic antidepressant; refer to pain specialist for severe cases
• Early antiviral treatment of acute shingles reduces risk

6. Mid-Facial Segment Pain

• Symmetric pressure/tightness over nasion, peri/retro-orbital, cheeks
• Patient may feel blocked nose but NO actual nasal obstruction
• Normal nasal endoscopy
• Normal CT sinuses
• No consistent trigger/relieving factors
• No nasal symptoms (rhinorrhoea, discharge)

7. Atypical Odontalgia / Phantom Tooth Pain

• Persistent tooth/jaw pain without dental cause
• Likely a form of persistent idiopathic facial pain (see below)
• Rx: Gabapentin, tricyclics, topical anaesthetics, opioids

8. Persistent Idiopathic Facial Pain (Atypical Facial Pain)

• Persistent facial pain not fitting other diagnoses
• Often chronic, diffuse, poor localization
• Associated with psychological distress
• Rx: Tricyclic antidepressants, cognitive behavioural therapy (CBT), pain clinic referral

9. Post-Surgical / Traumatic Neuralgia

• Pain following nasal surgery or trauma
• Due to injury to branches of trigeminal nerve (nasociliary, infraorbital nerve)
• Rx: Amitriptyline, gabapentin, pregabalin, local anaesthetic + steroid infiltration

10. Analgesic/Medication Overuse Headache

• Common complication - excessive analgesic use paradoxically worsens headache
• Dull, diffuse, band-like headache typically in the morning
• Drugs implicated: paracetamol, NSAIDs, triptans, codeine
• Rx: Withdraw offending drug (supervised); replace with preventive therapy

Diagnostic Approach - Simple Flow

Facial Pain
     |
Is there purulent discharge + fever + CT/endoscopy abnormality?
     |
    YES → Sinogenic (treat sinusitis)
     |
     NO → Non-sinogenic
          |
          Unilateral stabbing/lancinating? → Trigeminal Neuralgia
          Unilateral severe + autonomic features? → Cluster Headache / TAC
          Pulsatile + nausea + photophobia? → Migraine
          Bilateral pressure + normal endoscopy/CT? → Tension / Mid-facial segment pain
          Post-shingles rash? → Post-herpetic neuralgia
          Chronic + no diagnosis? → Persistent idiopathic facial pain

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