Facial Pain and Headache: Treatment for the Pain Syndromes Most Often Misdiagnosed
- May 20
- 6 min read
Author : Prof. Dr. Andrew J. Fishman, M.D. Board-Certified Surgeon in Otology, Neurotology, Skull Base, Head and Neck, Facial Reconstructive, and Sinonasal & Maxillary Surgery
If You Are Reading This After Years of Pain
You may have already seen a number of physicians. You may have been told your pain is
“just” migraine, or TMJ, or sinus, or stress. You may have been started on medications that
did not work, that worked briefly, or that had side effects worse than the pain itself. You may
have been told there is nothing more to do.
Facial pain is one of the most difficult diagnostic areas in medicine. The face is supplied by
multiple sensory nerves, and the pain produced by an irritated cranial nerve can mimic
almost any other kind of facial discomfort — sinus pressure, dental ache, jaw pain,
headache. A patient with classical trigeminal neuralgia is, on average, misdiagnosed for
years before the correct diagnosis is made. A patient with glossopharyngeal neuralgia or
Eagle syndrome can be misdiagnosed for even longer because the conditions are rare and
not familiar to most physicians. A patient with occipital neuralgia can be told they have
“tension headache” and prescribed treatments that have nothing to do with their actual
problem.
The information on this page is written for the patient who has been through this — who has
had pain for months or years, who has seen multiple specialists, and who is looking for a
more careful assessment than they have received so far. The first job of a thoughtful
consultation for facial pain is to identify exactly what kind of pain you have. Once the
diagnosis is correct, the treatment usually becomes clear.
What I Treat and What I Refer
Before describing what I treat, let me be clear about what I do not. Facial pain has several
distinct categories, and they belong with different specialists.
Pain from the temporomandibular joint (TMJ disorders) is the domain of maxillofacial
surgery. Patients with TMJ disorders — clicking and locking of the jaw, pain with chewing,
restriction of mouth opening — are best treated by oral and maxillofacial surgeons whose
practices are focused on the joint. The temporomandibular joint is their primary
subspecialty, and the long experience they bring to its care is not something I can or should
replace. If your pain is coming from the temporomandibular joint, the right referral is to a
maxillofacial surgeon, and identifying TMJ as the source is part of the workup any patient
with facial pain deserves.
Pain from the teeth, gums, and oral mucosa is the domain of dentistry and oral
medicine. Patients with dental pain, periodontal disease, burning mouth syndrome, or pain
related to the oral mucosa are best treated by dentists, endodontists, and oral medicine
specialists. Many patients with “facial pain” turn out, on careful evaluation, to have dental
sources of their pain — sometimes a tooth that has not been correctly identified as the
cause. A complete dental evaluation is part of working up any patient with persistent facial
pain.
Pure migraine and primary headache disorders are the domain of neurology. Many
patients who believe they have “sinus headache” or “facial pain” actually have migraine in a
variant that produces facial rather than purely head pain. These patients benefit from
headache specialist care, including modern preventive medications and specific abortive
therapies. Operating on the sinuses or the nerves of a patient with migraine does not
produce relief.
Pain from the sinuses themselves is covered in detail in the separate sinus and nasal
surgery section of this site. True sinus pain is uncommon but real, and it responds to
appropriate treatment of the underlying sinusitis when the diagnosis is confirmed.
What I do treat is the group of facial pain conditions that fall within neurotology,
cranial nerve surgery, and skull base surgery:
Trigeminal neuralgia — the most common and most treatable of the cranial neuralgias,
with both medical and surgical options including microvascular decompression
Glossopharyngeal neuralgia — a rarer condition with severe pain in the throat, base of the tongue, and deep ear, treatable with both medical and surgical approaches
Occipital neuralgia — pain at the base of the skull and back of the head, treated with
nerve blocks, medications, botulinum toxin, and selected procedures
Auriculotemporal neuralgia — pain in the temple region in front of the ear, often
following parotid surgery, trauma, or compression
Eagle syndrome — pain caused by an elongated styloid process at the base of the skull, treated surgically with excellent outcomes
Other less common neuralgias and facial pain conditions within the cranial nerve and skull base territory
This is the area where my background as a neurotologist and cranial base surgeon brings
specific expertise — the cranial nerves and the territory they pass through.
What Makes This Approach Different
Microsurgical technique and cranial base experience. The surgical procedures used to
treat several of the facial pain syndromes — most importantly microvascular decompression
for trigeminal and glossopharyngeal neuralgia — are skull base operations performed under
the operating microscope at 10× to 25× magnification. The approach to the trigeminal nerve
at the brainstem is the retrosigmoid approach — the same skull base corridor used for
vestibular schwannoma surgery, an operation I perform routinely. A surgeon with this skull
base background operates in this territory comfortably and frequently.
Deep three-dimensional knowledge of skull base and cranial nerve anatomy. The
cranial nerves run through some of the most anatomically complex territory in the body —
through the cavernous sinus, around the carotid artery, through the temporal bone, around
the brainstem, and out through specific bony foramina. Identifying the source of a facial
pain syndrome and choosing the right operation requires precise knowledge of where each
nerve runs and how it can be irritated. This anatomic understanding has been built through
a career operating in this region and through published academic work and teaching in skull
base radiologic anatomy on both CT and MRI. Every facial pain case begins with a detailed
personal review of the patient’s imaging, with attention to the specific cranial nerve and the
specific structures along its course that could be responsible for the pain.
The full range of treatment options, in order. Facial pain treatment is not a single
operation. It is a sequence of steps: accurate diagnosis first, medical therapy when
appropriate, nerve blocks when they are useful both diagnostically and therapeutically, and
surgery when medical and minimally invasive options have not solved the problem. Patients
are not pushed toward surgery as a first option. The patients who do best are those whose
treatment is matched to their specific diagnosis and stage of disease, with surgery reserved
for the situations where it is genuinely the best option.
Volume and experience in cranial nerve surgery. Across a career spanning academic
medical centers in the United States and Europe, I have performed thousands of
microsurgical operations involving the cranial nerves and skull base — including the
retrosigmoid skull base approach used for trigeminal and glossopharyngeal microvascular
decompression. The decisions made during these operations are the same kind of
microsurgical judgments that determine outcomes in any cranial nerve procedure.
Questions to Ask Any Surgeon Before Facial Pain Surgery
1. What is the specific diagnosis driving the recommendation for surgery, and has it
been confirmed by appropriate imaging and, where applicable, by diagnostic nerve
blocks?
2. Have all reasonable medical treatments been tried first, and at adequate doses?
3. What operation is being recommended, and how many of these specific operations
has the surgeon performed?
4. Will the operation be performed under the operating microscope, and what is the
surgeon’s experience with the relevant skull base or cranial nerve approach?
5. What is the realistic expectation for pain relief, the risk of recurrence, and the rate
of complications?
6. If the diagnosis is uncertain or the surgery does not work, what is the next step?
You are entitled to clear, specific answers. A surgeon who answers in generalities, or who
recommends surgery before medical therapy has been adequately tried, is not the surgeon
you want.
Related Reading
