Facial pain (trigeminal neuralgia)

What causes facial pain?

After toothache, the most common cause of facial pain is temporomandibular disorder (TMD), a problem with your jaw joint or the muscles that move it. Nerve-related causes include:

• trigeminal neuralgia, usually caused by a blood vessel pressing on the nerve that carries feeling from your face, though it can also be linked to conditions such as multiple sclerosis or a tumour
• persistent idiopathic facial pain (previously called atypical facial pain), a constant pain on one side of the face with no clear cause
• burning mouth syndrome and phantom tooth pain
• nerve injury after dental surgery, such as removal of a wisdom tooth or a local anaesthetic injection.

Other causes include migraine, sinusitis (though this is often over-diagnosed, since true sinusitis usually also causes a blocked or runny nose), tooth or gum problems, and shingles or cold sores. Rarely, facial pain is caused by temporal arteritis, mainly in people over 70, or by head and neck cancers.

Are there different types of facial pain?

Facial pain is often grouped by where it comes from:

• toothache, from problems such as cavities or abscesses
• jaw pain, from TMD or a jaw injury
• nerve pain, such as trigeminal neuralgia
• vascular pain, linked to conditions such as migraines
• atypical facial pain, which doesn't fit a clear pattern and has no obvious cause.

Trigeminal neuralgia itself has a distinctive pattern: sudden attacks of sharp, shooting or electric-shock-like pain, usually on one side of the face, lasting from a few seconds to about 2 minutes, and stopping as suddenly as they start. Attacks can happen regularly for days, weeks or months, then ease off for months or years at a time (remission), though these pain-free periods tend to get shorter over time. Some people go on to develop a more constant aching, throbbing or burning feeling as well.

How is facial pain diagnosed?

Diagnosis is based mainly on your history and the pattern of your symptoms, since there's no specific test for conditions like trigeminal neuralgia. Your GP will ask when the pain started, what it feels like, how long it lasts, and what triggers or eases it, and will usually check with a dentist to rule out a dental cause first. Depending on what they suspect, you may also have:

• Blood tests: Such as ESR or CRP, if temporal arteritis is a possibility, particularly if you're over 70
• An MRI scan: If you have trigeminal neuralgia and might be suitable for surgery, or if your symptoms are unusual
• A referral to a specialist: Such as a neurologist, oral surgeon or ENT (ear, nose and throat) doctor, depending on the suspected cause.

It can take time, sometimes a few years, for some causes of facial pain, including trigeminal neuralgia, to be confirmed.

How is facial pain treated?

Treatment depends entirely on the cause. If temporomandibular disorder (TMD) is behind your pain, self-management often helps, since more than 75% of cases don't get worse over time: Here are some things you can try:

• Cut back on caffeine, which can increase muscle tension
• Try a softer diet for 5 to 10 days when pain flares up, then return to your normal diet
• Avoid habits that strain your jaw, such as chewing gum or biting your nails
• Be aware of jaw tension, and try to keep your teeth apart except when eating
• Practise slow, deep breathing to help you relax
• Apply heat or ice to the painful area for 15 to 20 minutes, twice a day
• Gently massage the muscles at your temples and jaw.

For trigeminal neuralgia, the usual first treatment is an anticonvulsant medicine called carbamazepine, taken several times a day and increased gradually until it controls the pain. It's usually continued long-term, and if you go into remission, your doctor will help you reduce the dose slowly rather than stopping suddenly. If carbamazepine doesn't help, causes too many side effects, or you can't take it, other options include:

• other anticonvulsant medicines
• minor procedures that damage the nerve to stop it sending pain signals, though these usually only work for a few years
• major surgery to move a blood vessel away from the nerve (microvascular decompression), which offers the best chance of long-term relief but carries a small risk of serious complications, such as hearing loss or, very rarely, a stroke.

Other treatments for facial pain, depending on the cause, include tricyclic antidepressants such as amitriptyline for persistent idiopathic facial pain, referral to a dentist or ENT specialist for dental, jaw or sinus-related pain, and muscle relaxing injections or nerve blocks for pain that hasn't responded to other treatments. At home, an ice pack, a heat pack, gentle massage, or over-the-counter pain relief such as paracetamol or ibuprofen can help with mild facial pain, though these often don't help trigeminal neuralgia.

When should I see a doctor?

See a GP if you have frequent or persistent facial pain, particularly if standard painkillers don't help and a dentist has ruled out a dental cause. Call 999 or go to A&E if facial pain happens alongside:

• symptoms of a heart attack, such as pain in your arm, chest, shoulder or neck
• symptoms of a stroke, such as tingling, numbness, weakness or loss of movement
• a severe skin rash with flushing, blisters or ulcers, if you're taking carbamazepine, since this can be a sign of a rare but serious reaction.

See a doctor if you're over 70 and have new facial pain, especially around your temples, as this occasionally needs urgent investigation to rule out a rare condition called temporal arteritis.