When a patient complains of pain in the face rather than the head the physician has to consider foremost the possibilities of dental disorders (which accounts for up to 90% of pain in and about the face), sinus disease, esp. of the maxillary sinuses, temporomandibular joint (TMJ) dysfunction, eye disorders, lesions of the oropharynx or posterior third of the tongue, trigeminal neuralgia and chronic paroxysmal hemicrania.
The key to the diagnosis is the clinical examination because even the most sophisticated investigation may provide no additional information.
Table F1 Pa in in the face: diagnostic strategy model
Serious disorders not to be missed
aneurysm of cavernous sinus
internal carotid aneurysm
ischaemia of posterior inferior cerebellar artery
carcinoma (e.g. mouth, sinuses, nasopharynx)
metastases (e.g. orbital, base of brain)
Pitfalls (often missed)
Migraine variants (continues)
Eye disorders: glaucoma, iritis, optic neuritis
Chronic dental neuralgia
Parotid gland: mumps, other infection, carcinoma, sialectasis
Atypical facial pain
Red flag pointers for facial pain
Persistent pain: no obvious cause
Unexplained weight loss
Trigeminal neuralgia: possible serious causes
Herpes zoster involving nose
Person >60 years: consider temporal arteritis, malignancy
Cervical spinal dysfunction
The upper cervical spine can cause facial pain from lesions of C2 or C3 via the lesser occipital or greater auricular nerves which may give pain around the ear. It is important to remember that C2 and C3 share a common pathway with the trigeminal nerve.
Dental caries, impacted teeth, infected tooth sockets and dental roots can cause pain in the maxillary and mandibular regions. Impacted third molars (wisdom teeth) may be associated with surrounding soft tissue inflammation, causing pain which may be localised to the mandible or radiate via the auriculotemporal nerve to the ear.
Features of dental caries
Pain is usually confined to the affected tooth but may be diffuse.
Pain is almost always aggravated by thermal changes in the mouth:
Pain may be felt in more than one tooth.
Dental pain will not cross the midline.
Arrange urgent dental consultation.
Pain relief aspirin 600 mg (o) 4–6 hrly or paracetamol 0.5–1 g (o) 4–6 hrly.
If pain severe, add ibuprofen 400 mg (o) 4–6 hrly to paracetamol.
Dental infection (e.g. tooth abscess) Dental treatment may relieve but if moderate to severe: