What could be causing chronic pain and pressure in the head, specifically in areas such as the forehead, nose, cheekbones, temples, and jaw, that worsens with eye movement?

Chronic Facial Pain with Eye Movement Exacerbation: Diagnostic Approach

Your symptom pattern—chronic pain in specific, reproducible locations (forehead, occiput, nose, cheekbones, temples, jaw) that worsens with eye movement and involves constant tightness around the inner eye corners for two years—most strongly suggests temporomandibular disorder (TMD) with possible coexisting chronic migraine or myofascial pain syndrome. 1, 2

Primary Diagnostic Considerations

Temporomandibular Disorder (TMD)

• TMD is the most common cause of chronic facial pain involving the temples, jaw, and cheekbones, particularly when bilateral and associated with muscle tension. 1, 2
• The British Journal of Anaesthesia identifies musculoskeletal TMD involving the muscles of mastication as frequently presenting with pain in the exact locations you describe: temples, jaw, and areas in front of the ears. 1
• Key features to assess include jaw clicking/locking, bruxism (teeth grinding/clenching), pain with prolonged chewing, and whether stress or fatigue worsens symptoms. 1, 2
• The reproducibility of pain in identical locations is characteristic of myofascial trigger points associated with TMD. 2

Chronic Migraine Component

• The involvement of eye movement exacerbating pain, combined with frontal and temporal locations, suggests a chronic migraine component may coexist with TMD. 1
• Chronic migraine is defined as headache on ≥15 days per month for >3 months, with ≥8 days having migraine features. 1
• The constant nature of your symptoms over two years without relief meets criteria for chronic daily headache. 1
• Pain around the inner eye corners that worsens with eye movement is consistent with periorbital migraine or tension-type headache. 1

Myofascial Pain Syndrome

• The British Journal of Anaesthesia emphasizes that myofascial pain presents with specific trigger points that reproduce pain in consistent patterns, exactly matching your description. 1, 2
• Associated factors include other chronic pain conditions, sleep disturbance, and psychological stress. 1, 2

Critical Red Flags to Exclude

Giant Cell Arteritis (GCA)

• If you are over age 50, giant cell arteritis MUST be excluded immediately, as it presents with temporal headache and can cause permanent vision loss. 3
• Jaw claudication (pain with chewing that improves with rest) is pathognomonic for GCA and requires immediate high-dose corticosteroids before any testing. 3
• However, GCA typically presents acutely over weeks, not chronically over two years, making it less likely in your case. 3
• The British Journal of Anaesthesia specifically warns that GCA must be distinguished from TMD, especially in patients over 50. 1, 2

Sinusitis

• Chronic rhinosinusitis can cause facial pain in the cheekbones, forehead, and nose, but typically includes nasal congestion, purulent drainage, or postnasal drip. 1
• The absence of nasal symptoms makes sinusitis less likely, but it should be considered if you have any nasal obstruction or discharge. 1

Neuropathic Ocular Pain

• The constant tightness around inner eye corners that never resolves could represent neuropathic ocular pain (corneal neuropathic pain). 1
• The "topical anesthetic test" can help: if topical anesthetic drops improve the eye pain, it suggests peripheral neuropathic pain; if no improvement, it suggests central or non-ocular causes. 1

Recommended Diagnostic Approach

Initial Clinical Assessment

1. Document pain characteristics systematically:

   • Timing: constant vs. episodic, time of day patterns, duration of episodes 1, 2
   • Aggravating factors: chewing, jaw movement, stress, fatigue, weather, posture 1, 2
   • Associated symptoms: jaw clicking/locking, teeth grinding, nasal symptoms, visual changes 1, 2

2. Physical examination should include:

   • Palpation of temporomandibular joints and muscles of mastication for tenderness 1, 2
   • Assessment of jaw range of motion and clicking 1, 2
   • Palpation of temporal arteries (if age >50) for tenderness or decreased pulse 3
   • Examination of teeth for dental pathology 1
   • Neurological examination including cranial nerves 1

Laboratory and Imaging

• No imaging is indicated initially for TMD or chronic migraine unless red flags are present. 1
• If age >50 with new-onset or worsening headache: obtain ESR and CRP immediately to exclude GCA, but do not delay treatment if clinical suspicion is high. 3
• CT or MRI of sinuses is NOT indicated unless you have persistent nasal symptoms or failed medical management. 1
• Brain MRI is indicated only if there are neurological deficits, progressive worsening, or concern for structural lesions. 4

Management Algorithm

First-Line Treatment (TMD/Myofascial Pain)

• Manual physical therapy with myofascial release techniques targeting trigger points in the temporalis, masseter, and pterygoid muscles should be the initial approach. 2
• NSAIDs for symptomatic relief, with consideration of topical lidocaine patches for localized areas. 2
• Dental evaluation for occlusal splint (night guard) to prevent bruxism. 1
• Reassurance and education about the benign nature of TMD, as lack of diagnosis significantly impacts quality of life. 1

Adjunctive Therapies

• If chronic migraine is confirmed (≥15 headache days/month), consider prophylactic treatment with topiramate, which has proven efficacy in chronic migraine. 1
• For neuropathic component around eyes: consider oral neuromodulators (gabapentin, pregabalin, amitriptyline, or nortriptyline), which require 3-4 months at therapeutic dose to assess efficacy. 1
• Cognitive behavioral therapy and relaxation techniques for the psychological component of chronic pain. 1, 2

When to Refer

• Refer to oral and maxillofacial surgery or TMD specialist if conservative management fails after 3 months. 1
• Refer to neurology if chronic migraine features predominate or if neurological symptoms develop. 1
• Refer to ophthalmology if eye pain persists despite treatment, for topical anesthetic test and evaluation of neuropathic ocular pain. 1

Common Pitfalls to Avoid

• Do not pursue extensive neuroimaging without clear neurological deficits or red flags—this delays appropriate treatment and increases cost without benefit. 1
• Do not attribute chronic facial pain to sinusitis without clear nasal symptoms and failed medical management. 1
• Do not miss GCA in patients over 50 by attributing symptoms to TMD—jaw claudication is the key distinguishing feature. 1, 3
• Do not expect immediate relief from neuromodulators—set expectations for 3-4 months of treatment before assessing efficacy. 1
• Do not overlook the biopsychosocial component—chronic facial pain patients often have depression, anxiety, and other chronic pain conditions that require multidisciplinary management. 1, 2