What are the possible causes and treatments for right-sided head and face pain?

Right-Sided Head and Face Pain: Diagnosis and Management

Initial Diagnostic Approach

Begin with a detailed pain history focusing on temporal pattern (continuous vs. episodic), quality (electric shock-like, dull aching, burning), and triggering factors (light touch, chewing, cold foods, weather) to narrow the differential diagnosis. 1

Critical History Elements

• Temporal pattern: Episodic/paroxysmal pain suggests primary headache disorders or trigeminal neuralgia, while continuous pain points toward temporomandibular disorders (TMD), persistent idiopathic facial pain, or secondary causes 1
• Pain quality: Electric shock-like pain indicates trigeminal neuralgia; dull aching suggests TMD or sinusitis; burning quality points to neuropathic pain 1, 2
• Triggering factors: Light touch triggering is pathognomonic for trigeminal neuralgia; pain with chewing suggests TMD; pain before eating indicates salivary gland pathology 1
• Associated symptoms: Autonomic features (tearing, nasal congestion, eyelid swelling) suggest trigeminal autonomic cephalalgias; jaw clicking/locking indicates TMD 1

Red Flags Requiring Immediate Evaluation

• Age >50 years with new-onset temporal area pain: Rule out giant cell arteritis immediately, as this can cause permanent vision loss 1, 2
• Progressive neuropathic pain: Consider malignancy, which can present as worsening unilateral facial pain 1, 2
• Neurological deficits: Altered sensation, motor weakness, or visual changes require urgent neuroimaging 1

Common Diagnoses and Specific Management

Temporomandibular Disorders (Most Common Non-Dental Cause)

TMD affects 5-12% of the population and should be managed initially with patient education, reassurance, and simple physiotherapy rather than invasive interventions. 1, 2

• Presentation: Unilateral or bilateral dull aching pain in jaw/face, worse with chewing, often with jaw clicking or limited opening 1
• First-line treatment: Education and self-management strategies (improved self-efficacy leads to fewer symptoms), combined with physiotherapy 1
• Second-line treatment: Hard full-coverage stabilization splints worn at night may provide benefit, though long-term education may be more effective 1
• Avoid: Soft splints or poorly fitted appliances can cause tooth movement and malocclusion 1
• Consider: Cognitive behavioral therapy for patients with poor coping strategies or comorbid depression 1

Trigeminal Neuralgia

Carbamazepine is the first-line treatment for trigeminal neuralgia, with neurosurgery reserved for refractory cases. 1, 2, 3

• Presentation: Severe, unilateral, electric shock-like pain lasting seconds, triggered by light touch to specific facial areas 1
• First-line medication: Carbamazepine (start low, titrate to effect) 1, 2, 3
• Surgical referral: Consider neurosurgery for patients with inadequate pain control despite optimal medical management 1

Persistent Idiopathic Facial Pain (PIFP)

Amitriptyline is the primary pharmacological treatment for persistent idiopathic facial pain, combined with cognitive behavioral therapy. 1, 2, 4

• Presentation: Continuous unilateral facial pain without clear organic cause, often in patients with other chronic pain conditions and mood disorders 4
• First-line treatment: Tricyclic antidepressants (amitriptyline preferred) 1, 2, 4
• Alternative antidepressants: Venlafaxine or fluoxetine if tricyclics are contraindicated 4
• Essential adjunct: Cognitive behavioral therapy to address pain catastrophizing and improve coping 1, 4
• Specialist referral: Consult neurology specialized in facial pain when first-line treatment fails 1

Sinusitis-Related Facial Pain

Facial pain attributed to sinusitis should be treated medically first, with surgery considered only if medical treatment fails AND other sinonasal symptoms improve with treatment. 1

• Important caveat: Facial pain alone is rarely caused by chronic rhinosinusitis; most patients with "sinus headache" actually have migraine or tension-type headache 1, 5
• Diagnostic criteria: Pain should be accompanied by nasal congestion, purulent discharge, or documented sinus inflammation 1
• Medical treatment: Trial of appropriate medical therapy for sinusitis 1
• Surgical consideration: Only if pain improves together with other CRS symptoms during medical treatment, suggesting true sinus origin 1
• Critical warning: Facial pain without other nasal complaints or examination abnormalities should NOT be addressed surgically 1

Primary Headache Disorders with Facial Presentation

Consider migraine or trigeminal autonomic cephalalgias when episodic unilateral facial pain is accompanied by autonomic symptoms or migraine features. 1, 5

• Migraine with facial pain: May present with unilateral facial pain plus nausea, photophobia, or phonophobia 5
• Treatment: Trial of triptans (e.g., sumatriptan) for acute attacks 1, 5, 6
• Trigeminal autonomic cephalalgias: Characterized by ipsilateral autonomic symptoms (tearing, nasal congestion, eyelid swelling) 1
• Medication overuse headache: Consider in patients using analgesics ≥10-15 days per month for >3 months 1

Dental and Oral Causes

Dental pathology causes pain localized to specific teeth, worsened by hot/cold/sweet stimuli, and requires dental referral. 1

• Examination: Use good lighting to examine teeth, gingiva, and oral mucosa 1
• Salivary stones: Intermittent pain just before eating, tender gland on palpation, requires oral/maxillofacial surgery referral 1
• Oral mucosal diseases: Painful lesions visible on examination (herpes, lichen planus, ulceration) 1

Treatment Algorithm

1. Exclude red flags (age >50 with temporal pain, progressive symptoms, neurological deficits) 1, 2
2. Determine temporal pattern: Episodic suggests neuralgia or primary headache; continuous suggests TMD or PIFP 1, 2
3. Identify triggering factors: Light touch = trigeminal neuralgia; chewing = TMD; eating = salivary pathology 1, 2
4. Check for autonomic symptoms: Present = consider trigeminal autonomic cephalalgias or migraine 1
5. Examine for local pathology: Dental disease, oral lesions, sinus tenderness 1, 5
6. Initiate specific treatment based on diagnosis:
   • TMD: Education + physiotherapy ± splint 1, 2
   • Trigeminal neuralgia: Carbamazepine 1, 2, 3
   • PIFP: Amitriptyline + cognitive behavioral therapy 1, 2, 4
   • Migraine: Triptans for acute attacks 1, 5, 6
7. Refer to neurology if first-line treatment fails or diagnosis remains uncertain 1, 2

Critical Pitfalls to Avoid

• Do not perform sinus surgery for isolated facial pain without other sinonasal symptoms or clear improvement with medical treatment 1
• Do not assume "sinus headache" without confirming true sinusitis; most are actually migraine or tension-type headache 1, 5
• Do not overlook giant cell arteritis in patients >50 years with new temporal/facial pain 1, 2
• Do not use soft splints for TMD without proper occlusal consideration, as they can cause dental malocclusion 1
• Recognize medication overuse headache in patients using acute pain medications frequently 1