Orofacial pain is very common in Primary Care, with reported prevalences in surveys of up to a quarter of the population. There are many causes, and the majority relate to neurological, dental or musculoskeletal causes. The key to diagnosis and management is the history and investigations rarely add value.
Sinus pain is constant and ALWAYS associated with nasal symptoms and does not generally cause facial swelling. If there is visible facial swelling referral for iv antibiotics should be considered. Sinus pain is only significant if it lasts longer than a week.
Migraine can be associated with a runny or blocked nose or a swollen or red face – those symptoms are episodic but can last up to 4 days. They can also be associated with midfacial segment pain and cluster headaches. The BMJ has a very useful open-access infographic.
Orofacial pain is commonly misattributed to rhinosinusitis but is not a hallmark feature of the condition: further investigation (CT or endoscopy) will only confirm the diagnosis in about 10%.
Chronic Facial Pain
This is pain lasting more than 12 weeks, and most relates to non-ENT conditions. In addition to migraine, the commonest causes are:
- Pain from teeth or jaw which can radiate to the temple or neck
- Chronic daily headache
- Trigeminal neuralgia (rare)
- Referred pain from the neck, though Lothian neurologists consider this uncommon.
The Patient Information Leaflet gives further detail.
Diagnoses associated with nasal blockage or congestion:
- MIGRAINE is the cause of the majority of pain in the sinus area and should be considered initially as the most likely cause of chronic orofacial pain. Pain may involve the lower half of the face and be associated with trigemino-autonomic symptoms (rhinorrhoea, nasal blockage and eye symptoms).
- CLUSTER HEADACHES – are very severe, unilateral, short-lived but occur in clusters over time and may be associated with lacrimation and conjunctival injection. All new diagnoses should be referred.
- RHINOSINUSITIS
The four cardinal symptoms of rhinosinusitis are nasal blockage, nasal discharge, facial pain and reduced sense of smell: the first two are required for the diagnosis. Pain is more often associated with ACUTE but not chronic sinusitis – and there are then symptoms and signs of infection due to a blocked non-draining sinus.
Acute sinusitis presents with severe unilateral pain, fever and nasal obstruction. Recurrent acute rhinosinusitis is rare.
The ENT rhinosinusitis page gives more detail.
RefHelp has further detail on neurological differentials and on headache management.
No nasal blockage or congestion:
- TENSION HEADACHE has a lifetime prevalence of almost 80% and, like migraine, is chronic if it occurs more than 15 days per month. It is described as a featureless headache but can cause pericranial tenderness with tenderness in the neck and jaw muscles too.
- TEMPOROMANDIBULAR DISORDER – associated with the TMJ site, clicking or locking jaws and TMJ laxity.
- TRIGEMINAL NEURALGIA – please see advice on differentiating primary headache disorders
- MIDFACICAL SEGMENT PAIN is similar to that of a tension headache, with a bilateral T-shaped distribution over the nose and both frontal areas. Pain is constant, and like cluster headaches it can be associated with soft tissue tenderness as well as nasal symptoms.
Management of chronic facial pain depends on the diagnosis. Patient understanding is key and the facial pain patient leaflet gives more detail.
Who to Refer:
Please see ENT indications and neurological indications.
Who not to Refer:
Chronic orofacial pain, even with symptoms of nasal congestion or blockage, is more likely to be migrainous, and that diagnosis should be considered first.
Where rhinosinusitis is suspected, please optimise primary care management before considering referral.
