Facial Pain

 

This guideline applies to adults aged 16 years and over.

 

Introduction

Facial pain is a common problem, with many potential underlying causes. In the absence of other nasal symptoms (i.e. discharge, obstruction etc.) it is typically not due to sinus problems.

 

Red Flag Features

Nasal Malignancy should be excluded in the context of new onset, persistent and/or rapidly progressive:

• Unilateral facial pain and/or swelling
• Unilateral epistaxis or crusting with nasal obstruction – simple epistaxis is typically unilateral at presentation
• Clear watery nasal discharge (CSF leak presents like a dripping tap)
• Bulging eye associated with visual disturbance, painful eye movements and/or double vision
• Dental changes e.g. loosening of upper teeth

 

Differential Diagnoses

• Rhinosinusitis
• Facial migraine
• Mid-segment facial pain
• Tension-type headache
• Cluster headaches
• Trigeminal neuralgia
• TMJ disorders
• Dental-related neuralgia
• Giant Cell arteritis
• Atypical facial neuralgia – an unnamed neuralgia. May have a history of surgery or trauma close to the site of pain. Sometimes linked with mental health problems; can be challenging to determine which is the primary versus secondary problem.

Not an exhaustive list.

 

Investigation

Consider CT head if facial swelling is present and the clinical picture is not one of simple acute rhinosinusitis. X-ray is not indicated.

 

Management Optimisation

• Rule out red flag features.
• Provide patient information on likely cause.
• Advise symptom diary to help identify triggers to avoid.
• Treat underlying condition – depending on the likely diagnosis, this may be manageable in primary care, or may require referral to an appropriate specialist, such as ENT, Rheumatology, MaxFax, Neurology.

 

Advice and Guidance

ENT, Neurology and Pain Services Advice and Guidance is available if required, depending on likely underlying cause.

Refer any suspected nasal malignancy via ENT Advice and Guidance – the consultant will consider the clinical information and advise regarding appropriate prioritisation and urgency of referral. Do not send via Fast Track ENT Suspected Cancer or urgent ENT OPA.

There is no MaxFax Advice and Guidance service available.

 

Referral

Giant Cell Arteritis (GCA) Pathway:

• Contact Rheumatology on-call the same day by telephone if GCA suspected.
• If visual symptoms, refer same day to the Emergency Eye Clinic by completing the Referral form and emailing to rch-tr.EmergencyEyeClinic@nhs.net.

See RMS guidance on GCA for more detailed information.

 

Neurology Hot/Rapid Access Clinic:

• Discuss with on-call neurologist and send an urgent referral via Neurology Advice and Guidance detailing for the Hot/Rapid Access Clinic and who it has been accepted by.

For patients who require very urgent intervention, but not admission e.g. uncontrolled cluster headaches.

 

Routine* Neurology Referral Criteria:

• Migraine prophylaxis unsuccessful after at least 3 agents have been tried at a reasonable dose for a reasonable length of time.
• Uncontrolled cluster headaches
• Tension headache for consideration of acupuncture (neurology will refer to Pain Clinic).

Not an exhaustive list.

Required information: headache diary and list of medications tried.

*Upgrade to Urgent Referral if patient has very disabling symptoms or serious secondary cause is suspected, but criteria for suspected brain tumour, intracranial bleed or infection are not met.

 

Routine Adult ENT Referral Criteria:

• Facial pain with nasal symptoms, including obstruction and discharge, that has failed to respond to a 3-month trial of adequate medical management.

Facial pain in isolation is not an indication for referral to ENT.

 

Routine MaxFax Referral Criteria:

• TMJ disorders/dysfunction
• Dental-related neuralgia

 

Pain Clinic Referral Criteria:

• Severe, intractable facial pain once red flags and alternative pathologies have been excluded through appropriate investigation, obtaining specialist opinion where required, and where usual primary care management has been exhausted.

See RMS guidance on Pain Services for more detailed information.

 

 

Supporting Information and References

ENT UK – Facial Pain

The Migraine Trust – Keeping a Headache Diary

 

Page Review Information

Review date	09 January 2025
Next review date	09 January 2027
GP speciality lead	Dr Laura Vines
Contributors	Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon Dr Madeleine Attridge, RMS GP