Makindo Medical Notes

😖 Facial pain is a common but challenging clinical presentation. It may arise from neurological, ENT, dental, vascular, or systemic causes. 🎯 Careful history and focused examination are key — as is knowing the appropriate investigation and when to escalate.

📖 Overview

Facial pain can range from benign dental disease to sight- or life-threatening conditions such as giant cell arteritis. Understanding the spectrum of causes — from trigeminal neuralgia to sinus tumours — helps clinicians direct investigations and management appropriately. The table below summarises common causes, their diagnostic work-up, and typical management strategies.

🩺 Clinical History and Assessment

A careful history is the cornerstone of diagnosing facial pain. Key questions guide you towards neurological, dental, ENT, or vascular causes.

• 🗺️ Location & radiation: Is pain periorbital, maxillary, mandibular, scalp, or intraoral?
• ⏱️ Onset & duration: Sudden sharp "electric" (trigeminal neuralgia) vs throbbing over hours (migraine).
• 🔄 Pattern & triggers: Chewing, touching the face, cold wind (TN); chewing causing jaw fatigue (GCA); night-time clustering (cluster headache).
• 🧾 Associated symptoms: - Nasal obstruction/discharge (sinusitis). - Rash or vesicles (shingles). - Fever, swelling, dental history (abscess). - Visual disturbance, scalp tenderness, jaw claudication (GCA).
• 💊 Past medical history: MS (increases risk of TN), autoimmune disease, vascular risk factors.
• 🧠 Red flags not to miss: - Visual loss or diplopia. - Jaw claudication. - Weight loss, systemic symptoms. - Neurological deficit. - Severe pain unresponsive to simple analgesia.

👩‍⚕️ Examination

• 🧾 General: Vitals, systemic signs (fever, weight loss, malaise).
• 🦷 Oral cavity: Teeth, gums, swelling, fluctuant abscesses.
• 👃 ENT: Nasal congestion, sinus tenderness, nasal endoscopy if available.
• 🧠 Cranial nerves: Trigeminal sensory distribution, corneal reflex, motor function of jaw.
• 👁️ Ophthalmology: Fundoscopy (papilloedema/ischemic optic neuropathy in GCA).
• 🫀 Temporal arteries: Palpate for tenderness, thickening, or reduced pulsation.

⚕️ Management Principles

Treatment should be directed at the underlying cause, but general principles apply:

• 🚨 Urgent recognition of emergencies: - GCA → high-dose steroids immediately to prevent blindness. - Orbital cellulitis/dental abscess with airway compromise → urgent antibiotics/surgery.
• 💊 Targeted pharmacotherapy: - Trigeminal neuralgia: carbamazepine. - Migraine/cluster headache: triptans, oxygen, preventives. - Sinusitis: antibiotics, decongestants, nasal steroids.
• 🔪 Surgical input: - ENT: sinus surgery, drainage of abscesses. - Neurosurgery: microvascular decompression in refractory TN. - Dental: root canal or extraction.
• 🤝 Multidisciplinary team: Neurology, ENT, maxillofacial, dentistry, rheumatology, ophthalmology depending on suspected diagnosis.
• 📈 Follow-up: Monitor chronic cases (e.g., TN, migraine) and prevent recurrence with prophylaxis where indicated.

💡 Clinical Teaching Pearls

• ⚡ Trigeminal neuralgia is classically triggered by light touch such as shaving or brushing teeth.
• ⏱️ GCA is one of the few conditions where treatment (steroids) must be started before biopsy.
• 🦷 Always consider dental pathology first in unilateral lower facial pain — it’s common and treatable.
• 👁️ Visual disturbance + headache in an older adult = assume GCA until proven otherwise.
• 🌍 Cultural/epidemiological context matters: sinus tumours are rare, but dental abscesses and sinusitis are everyday practice.

🧾 Differential Diagnosis of Facial Pain

Cause	Diagnostic Tests	Management
Trigeminal Neuralgia	- ⚡ Clinical diagnosis: sharp, stabbing pain in trigeminal distribution - 🧲 MRI: Exclude structural causes (tumours, MS)	- 💊 Carbamazepine: First-line - Alternative: gabapentin, baclofen - 🔪 Surgery: microvascular decompression, ablative procedures if refractory
Sinusitis	- 🤧 Clinical: facial pressure, congestion, purulent discharge - 🖥️ CT scan: Chronic/recurrent cases - 🔎 Nasal endoscopy: For chronic disease	- 💊 Decongestants, antibiotics (if bacterial) - 🌊 Saline irrigation - 🔪 FESS surgery for chronic/refractory cases
Temporomandibular Joint (TMJ) Disorder	- 🗣️ Clinical: jaw pain, clicking, locking - 🖥️ X-ray/MRI: Joint evaluation	- 💊 NSAIDs - 😬 Mouth guards - 🏋️ Physical therapy - 🔪 Surgery for severe joint disease
Cluster Headache	- ⏱️ Clinical: excruciating unilateral periorbital pain - 🖥️ CT/MRI: Rule out secondary causes	- 💨 100% oxygen therapy - 💉 Triptans (sumatriptan) - 💊 Verapamil for prevention
Dental Abscess	- 🦷 Clinical: tooth/gum pain, swelling, fever - 📸 Dental X-ray	- 💊 Antibiotics (e.g., amoxicillin) - 🔪 Drainage, root canal - ❌ Extraction if not salvageable
Shingles (Herpes Zoster)	- 🌋 Clinical: painful vesicular rash, dermatomal - 🔬 PCR/culture if atypical	- 💊 Antivirals (acyclovir, valacyclovir) - 💊 Pain relief: NSAIDs, gabapentin - 💉 Shingles vaccine for prevention
Giant Cell Arteritis (Temporal Arteritis)	- 🧠 Clinical: scalp tenderness, jaw claudication, visual changes - 🔬 ESR: Raised - 🔎 Temporal artery biopsy (gold standard) - 🖥️ Ultrasound “halo” sign	- 💊 High-dose corticosteroids (urgent) - 💊 Aspirin: reduce ischaemic risk - 📈 Monitoring for steroid side-effects
Glossopharyngeal Neuralgia	- 📢 Clinical: stabbing pain throat/tonsil/tongue base - 🧲 MRI: Exclude compressive lesion	- 💊 Carbamazepine or gabapentin - 🔪 Microvascular decompression for refractory pain
Migraine	- 🌪️ Clinical: pulsatile unilateral headache ± aura - 🧲 MRI if atypical	- 💊 Triptans for acute attacks - 💊 NSAIDs - 🛡️ Preventive: beta-blockers, anticonvulsants
Sinus Tumour	- 🖥️ CT/MRI: Define mass extent - 🔬 Biopsy: Confirm histology	- 🔪 Surgical resection - 💉 Radiotherapy/chemotherapy depending on type/stage - 📊 Imaging follow-up

💡 Key Teaching Points

• ⏱️ Time matters: GCA is a medical emergency due to risk of blindness.
• 🧠 Pattern recognition: Trigeminal vs glossopharyngeal neuralgia distinguished by distribution.
• 🦷 Don’t forget dental causes: Common and easily overlooked in ED presentations.
• 🌐 Multi-disciplinary care: ENT, neurology, dentistry, ophthalmology, and rheumatology often overlap in managing facial pain.

📚 Conclusion

Facial pain has a broad differential diagnosis, ranging from benign to life-threatening. A structured approach — considering nerve, sinus, joint, dental, vascular, and tumour-related causes — helps clinicians prioritise urgent conditions, order appropriate imaging, and initiate timely management.