Headache and Facial Pain

What is it?

Headache and facial pain are among the most common pain complaints. Headaches fall into two main groups: primary headaches, which are not caused by another condition (migraine, tension-type headache and cluster headache), and secondary headaches, which result from an underlying cause.

Nerve pain plays an important part in facial pain. Trigeminal neuralgia affects the area supplied by the trigeminal nerve, which carries sensation from the face. It causes brief, electric-shock-like attacks of pain lasting seconds, set off by simple things such as touching the face, talking or chewing. Occipital neuralgia is a shooting nerve pain that spreads from the back of the head towards the crown.

What causes it?

The causes depend on the type of pain:

• Migraine: a neurological condition with a genetic tendency, linked to oversensitive pain pathways in the brain. Lack of sleep, missed meals, stress and hormonal changes can trigger attacks.
• Tension-type headache: a mild to moderate pain that feels like a tight band around the head. It is linked to stress, tiredness and tension in the neck and shoulder muscles.
• Cluster headache: attacks of very severe pain around one eye that recur in bouts, sometimes with a watering eye and a runny nose on the same side.
• Cervicogenic headache: pain that arises from the joints and soft tissues of the neck and is felt in the head (neck pain).
• Nerve pain: in trigeminal neuralgia, a blood vessel pressing on the nerve is thought to be responsible in many cases. Occipital neuralgia results from irritation of the occipital nerves at the back of the head. Nerve pain after shingles can also affect the face.
• Other causes: jaw joint problems, dental and sinus disease, eye conditions and headache caused by overusing painkillers.

How is it diagnosed?

Diagnosing a headache relies largely on a detailed history. The location, character, duration and frequency of the pain, its triggers and any accompanying symptoms are explored. A headache diary kept for a few weeks is very helpful. A neurological examination looks for signs that point to a secondary cause.

For typical headaches without warning signs, scans are usually unnecessary. MRI is requested when warning signs are present, or in conditions such as trigeminal neuralgia when a structure pressing on the nerve needs to be looked for. Where needed, the assessment is shared with neurologists, dentists, ear, nose and throat specialists and ophthalmologists.

Treatment options

Treatment depends on the type of pain and is usually coordinated with neurology.

Conservative care

• Lifestyle: regular sleep, not skipping meals, drinking enough fluids, exercising regularly, and identifying and reducing triggers.
• Medication: treatment for attacks and, for people with frequent attacks, preventive treatment. Taking painkillers on many days a month can make headaches worse, so medication use is planned under medical supervision. In trigeminal neuralgia, medicines aimed at nerve pain are the first step.
• Physiotherapy and exercise: programmes for the neck and shoulder muscles in tension-type and cervicogenic headache.
• Psychological support and relaxation techniques: can make long-standing headache easier to manage.

Interventional pain treatments

For people whose pain does not respond to medication, or who cannot tolerate its side effects, interventional methods may be considered:

• Nerve blocks: in occipital neuralgia and some other headaches, injecting local anaesthetic around the relevant nerve can help with both diagnosis and treatment.
• Radiofrequency treatment: can be applied to the trigeminal ganglion in trigeminal neuralgia that has not responded to medication, to the occipital nerves in occipital neuralgia, and to the relevant joint nerves in the neck in cervicogenic headache. For treatments on the trigeminal nerve, side effects such as reduced feeling in the face are discussed in advance.
• Sympathetic nerve blocks: a sphenopalatine ganglion block may be considered in cluster headache and some facial pains, and a stellate ganglion block in selected head and facial pain.

In suitable patients these methods can provide a meaningful reduction in pain, but how much they help, and for how long, varies from person to person.

When is surgery considered?

For trigeminal neuralgia that does not respond to medication or interventional treatment, surgery to relieve pressure from a blood vessel on the nerve is assessed with a neurosurgeon. If a structural cause of headache is found, treatment is planned together with the relevant surgical specialty.

When should you see a doctor?

See a doctor if your headaches have changed in frequency or severity, if you are taking painkillers more and more often, or if you have severe attacks of facial pain triggered by touch. An algology (pain medicine) specialist, working alongside a neurological assessment, will consider interventional options suited to the type of pain; you can request an appointment through our contact page.