Facial pain - red flag symptoms

Red flag symptoms in facial pain and possible causes. With advice on key questions to ask, investigations to conduct and when to refer.

Red flags

  • Systemic upset
  • Progressive pain, disability and distress
  • Focal neurological deficit
  • Weight loss
  • Facial swelling or rash
  • Vision disturbance
  • Hearing loss/tinnitus/vertigo
  • Unilateral nasal obstruction/discharge


Approximately 15% of general practice consultations involve the head and neck.1 Facial pain can be a challenging consultation due to a variety of causes, patient distress and the clinical overlap with general dentistry.2 Most conditions are benign and self-limiting, however vigilance is needed to avoid misdiagnosis and exclude any progressive and life threatening pathology.

Local  Sinus disease
Dental caries/abscess/cyst
Salivary gland disorder such as sialolithiasis, mumps, parotitis
Temporomandibular disorders (TMDs)
Neoplasia (such as nasopharyngeal, brainstem)
Cranial neuralgia Primary: trigeminal or glossopharyngeal nerve
Secondary: intracranial
Vascular Giant cell arteritis (GCA)
Cluster headache
Carotid artery dissection
Atypical facial pain


Allow the patient to describe their symptoms. The SOCRATES acronym (site, onset, character, radiation, associated factors, timing, exacerbating/relieving factors, severity score) is a valuable aide-memoire.

Remember that the trigeminal nerve (ophthalmic, maxillary and mandibular divisions) conveys facial sensation and controls the muscles of mastication. The facial nerve innervates the muscles of facial expression and conveys taste from the anterior two thirds of the tongue.

Be mindful of certain conditions:

  • Trigeminal neuralgia causes a severe, unilateral, "shock-like" and paroxysmal facial pain, often triggered externally (for example by wind or shaving). Peak incidence is between 50-60 years age. Be cautious, as 5% of cases are bilateral, and 5-10% of cases can be due to multiple sclerosis plaques, acoustic neuroma, arterio-venous malformations and skull base abnormalities and not a compressive blood vessel. Glossopharyngeal neuralgia is rarer, with pain localised to the posterior tongue, throat and ear canal.3
  • Giant cell arteritis (GCA) is a neuro-ophthalmic emergency. Be alert to the older patient, with a previous misdiagnosis of migraine or tension headache and any associated systemic malaise, visual disturbance, shoulder/pelvic girdle stiffness or jaw claudication.
  • Temporomandibular disorder (TMD) is a complex condition present in 5-10% of the population. The triad of pain (on waking, chewing or yawning), jaw stiffness and joint clicking/popping may be described.  
  • Sialolithiasis (salivary gland calculi) involves pain classically associated with meals. The submandibular gland (angle of jaw) is involved in 80-90% of cases. Take note of absent saliva (total obstruction), exaggeration with acidic/sour foods, salivary gland swelling, fever or visible stone in the floor of the mouth.
  • Carotid artery dissection is a life threatening cause of facial pain that can be traumatic or spontaneous. Disregard may occur due to an absence of neurological signs or history of a TIA. The triad of headache/facial/neck pain, an ipsilateral Horner’s syndrome and contralateral stroke should be remembered.
  • Neoplasia can present unusually. Parotid tumours may cause a facial nerve palsy, whilst a nasopharyngeal carcinoma may cause a unilateral hearing loss, nasal obstruction and tearing due to obstruction of the nasolacrimal duct. Carcinoma of the maxillary antrum can present with unilateral epistaxis and nasal obstruction.
  • Herpes zoster: look for any painful, blistering rash and Hutchinson’s sign (vesicles on nose tip) suggestive of ophthalmic zoster. Ramsay Hunt syndrome may present with facial paralysis, ear pain and vesicles in the auditory canal.
  • Atypical facial pain is a diagnosis of exclusion that is chronic and idiopathic in nature. Pain may be worsened with stress or fatigue and associated with general body pains and mood disturbance3.

Questions to ask

Ask the patient whether there is/are:
  • Headache/previous migraine?
  • Pain related to eating?
  • Malaise, vision disturbance or scalp tenderness?
  • Facial rash or blisters?
  • Hearing loss/tinnitus?
  • Nasal obstruction/epistaxis?
  • Exacerbation by wind or touch?
  • Bruxism (jaw clenching/teeth grinding), jaw clicking?
  • Bleeding gums/tooth hygiene issues?
  • Altered mood and impact on quality of life such as sleep?


Assess for facial asymmetry, swellings such as parotitis or skin changes. Palpate the temporal arteries (assessing for prominence, tenderness or pulselessness), the muscles of mastication and the temporomandibular joints (assessing for crepitus and stiffness).

Palpate the frontal (supraorbital), ethmoid (either side of nose bridge) and maxillary sinus (over the zygomatic arch), remembering that sphenoid sinus disease may be inferred by retro-orbital pain or headache at the vertex. Intraorally, look for malocclusion, decay and mucosal lesions. Examine the cranial nerves.


Investigations may include:

  • Blood tests – including FBC, ESR, CRP 
  • Dental x-rays – for tooth misalignment, bone destruction, cysts, solid growths and sinus opacification. 
  • Temporal artery biopsy.
  • Sialography or ultrasound for salivary gland pathology such as duct stones.
  • MRI (brain, posterior fossa and cranial nerves).

When to refer

Refer acutely if the patient is systemically unwell or shows increasing disability or neurological signs. General dental practitioners can exclude an odontogenic cause and can refer onward to secondary care. 

In suspected GCA, early steroid treatment is required to prevent irreversible ischaemic complications such as vision loss, with urgent assessment by rheumatology or ophthalmology teams. 

Trismus, clicking jaws or recurrent jaw dislocation warrants a maxillofacial opinion. Referral to ENT is required for any nasal (obstruction, epistaxis) or ear (hearing loss, tinnitus, discharge) symptoms.   

Follow NICE cancer two-week guidelines if cancer is suspected, for example if there is progressive neurological deficit or  progressive parotid swelling.4

  • Dr Rupesh Amin is a GP in London

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  1. Griffiths E. Incidence of ENT problems in general practice. Journal of the Royal Society of Medicine 1979;72:740–2.
  2. Siccoli MMBassetti CLSándor PS. Facial pain: clinical differential diagnosis. Lancet Neurol. 2006 Mar;5(3):257-67.
  3. Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013 Jul;111(1):95-104. 
  4. NICE. Guidance on suspected cancer: recognition and referral. NG12. June 2015. 

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