What is the appropriate evaluation and management approach for an elderly female presenting with acute facial pain?

Acute Facial Pain in an Elderly Female: Evaluation and Management

In an elderly female with acute facial pain, immediately rule out giant cell arteritis by checking ESR and CRP within hours, as this is a medical emergency that can cause irreversible vision loss if missed. 1, 2

Critical Red Flag Assessment (First Priority)

Giant cell arteritis must be excluded first in any patient over 50 years old presenting with facial or jaw pain. 1, 2

Specific features to assess immediately:

• Jaw claudication (pain with chewing that improves with rest) 2
• Temporal artery tenderness or absent pulse on palpation 2
• Visual disturbances (blurred vision, diplopia, vision loss) 2
• Scalp tenderness when combing hair 2
• Fever, malaise, or weight loss 2
• Order ESR and CRP stat - elevated inflammatory markers support the diagnosis 2

If giant cell arteritis is suspected, initiate high-dose corticosteroids immediately and refer urgently to prevent permanent vision loss. 2

Systematic Diagnostic Approach

History Elements (Must Document)

Timing characteristics: 1

• Onset: sudden vs. gradual
• Duration: seconds, minutes, hours, or continuous
• Pattern: episodic vs. continuous

Pain quality: 1

• Electric shock-like, stabbing = suggests trigeminal neuralgia
• Burning, tingling = suggests neuropathic pain
• Dull ache = suggests musculoskeletal (TMD)

Aggravating factors: 1

• Light touch triggering pain = trigeminal neuralgia
• Chewing, jaw movement = TMD or dental pathology
• Hot/cold/sweet foods = dental pathology
• Jaw claudication = giant cell arteritis

Associated symptoms: 1, 2

• Clicking or locking of jaw = TMD
• Ear pain or fullness = TMD or otologic pathology
• Nasal congestion = sinusitis
• Visual changes = giant cell arteritis or neurologic pathology

Physical Examination (Specific Maneuvers)

Cranial nerve testing: 2

• Test all three branches of trigeminal nerve for sensory disturbances
• Numbness indicates neuropathic causes requiring imaging

Temporomandibular assessment: 2, 3

• Palpate masseter and temporalis muscles bilaterally for tenderness, hypertrophy, trigger points
• Assess jaw range of motion and listen for clicking

Vascular examination: 2

• Palpate temporal arteries for tenderness and pulse quality
• Check for scalp tenderness

Otoscopic examination: 2

• Perform pneumatic otoscopy to exclude middle ear pathology, cerumen impaction, or cholesteatoma

Common Acute Causes in Elderly Females

Dental Pathology (Most Common)

Dental disease is the most common acute cause of facial pain and should be evaluated by a dentist if pain is triggered by thermal changes or eating. 1, 4

Temporomandibular Disorders

TMD is the most common non-dental cause of chronic facial pain, with 5-12% prevalence, more common in women. 2, 3

• Presents as dull, aching pain in jaw muscles
• Worsened by chewing, jaw movement, or clenching
• May be bilateral or unilateral 1, 3

Trigeminal Neuralgia

Characterized by severe electric shock-like pain lasting seconds, triggered by light touch, eating, or brushing teeth. 1, 2

• Confined to trigeminal nerve distribution
• First-line treatment: carbamazepine 1, 3
• Requires MRI to exclude structural lesions 2

Sinusitis

Pain location depends on which sinus is affected, often associated with nasal congestion. 5, 6

Imaging and Laboratory Workup

When to order MRI of brain and trigeminal nerve: 2, 7

• Any suspected neuropathic pain
• Progressive pain
• Sensory disturbances on examination
• To exclude tumors, multiple sclerosis, or neurovascular compression

When to order CT temporal bone: 2

• Suspected chronic middle ear infection or cholesteatoma
• Persistent ear pain with otoscopic abnormalities

Laboratory tests: 2, 7

• ESR and CRP (mandatory if age >50 years)
• Complete blood count
• Consider vitamin B12, folate, glucose, thyroid function if chronic presentation

Initial Management Algorithm

For TMD (Most Common Non-Dental Cause):

Early diagnosis with reassurance and conservative therapy is most effective. 1, 3

• Patient education about benign nature 3
• Jaw rest (soft diet, avoid gum chewing) 2
• Heat or cold therapy 3
• NSAIDs for pain and inflammation 3
• Supervised jaw exercises and stretching 3
• Night splints fabricated by dentist 1

For Trigeminal Neuralgia:

Carbamazepine is first-line treatment. 1, 3

• Consider neurosurgery referral if poorly controlled 1

For Neuropathic Pain:

Gabapentin 300mg at bedtime, titrating to 900-3600mg daily in divided doses. 2, 7

• Alternative: amitriptyline or pregabalin 7

Pain Assessment in Elderly Patients

Use validated pain scales appropriate to cognitive status: 1

• Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) for cognitively intact patients 1
• Faces Pain Scale (FPS) for those with communication difficulties 1
• PAINAD or Doloplus-2 for patients with severe dementia 1

Observe pain behaviors in non-communicative patients: 1

• Facial grimacing, guarding, moaning
• Changes in activity patterns or social withdrawal
• Increased confusion or agitation

Multimodal Analgesia for Elderly

Use multimodal approach with acetaminophen, gabapentinoids, NSAIDs, and opioids only for breakthrough pain at lowest effective dose for shortest duration. 1

Consider regional nerve blocks if skills available, particularly for severe pain. 1

Common Pitfalls to Avoid

Missing giant cell arteritis in patients over 50 years results in permanent vision loss. 1, 2, 7

Performing invasive dental procedures when pain is the only symptom without objective findings can worsen atypical facial pain. 7, 6

Inadequate pain assessment in elderly with cognitive impairment leads to under-treatment, increased delirium risk, and poorer outcomes. 1

Failing to screen for psychological comorbidities (depression, anxiety) significantly increases chronicity risk. 2

Referral Indications

Refer to oral and maxillofacial surgery or ENT within 1-2 weeks if: 2

• Malignancy suspected (progressive pain, masses, non-healing ulcers, unexplained tooth mobility)
• Symptoms persist despite conservative management

Immediate referral if: 2

• Giant cell arteritis suspected
• Acute vision changes
• Rapidly progressive neurologic deficits

Multidisciplinary pain team referral for: 1

• Chronic facial pain not responding to initial management
• Complex cases with multiple comorbidities
• Significant psychological overlay