This paper reviews the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain should be defined in terms of frequency, duration and severity, and also in terms of quality, site and accompanying factors such as photophobia, nausea or vomiting and exacerbation on physical exertion. Rating the intensity of the pain from zero (no pain) to 10 (unbearable pain) is helpful because higher pain levels are associated with facial migraine or cluster headache. Pain distribution is important because migraine, cluster headache and paroxysmal hemicrania are usually unilateral. Daily and constant pain is unlikely to be of rhinogenic origin. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary.
The key points are as follows:
- Facial pain is an uncommon symptom of chronic rhinosinusitis. Only 20% of patients with purulent sinusitis or nasal polyposis confirmed by nasal endoscopy actually complained of facial pain.
- A temporal correlation of episodes of facial pain with rhinogenic symptoms of nasal obstruction, rhinorrhoea and hyposmia, and the presence of endoscopic and CT scan evidence of sinusitis are important to consider the pain to be of rhinogenic origin.
- Chronic facial pain is most likely to be due to nonrhinogenic causes. Facial pain of nonrhinogenic origin is a diagnosis of exclusion. Chronic tension-type facial pain followed by facial migraine is the commonest type of nonrhinogenic facial pain in a community setting.
- An eight week course of low-dose tricyclic antidepressants is a well tolerated and effective first line of treatment for chronic facial-tension-type pain and facial migraine. Addition of pindolol reduces analgesic consumption by reducing pain intensity.
