Approach to facial pain and «sinus headache»
- Approach to a complaint
Facial pain without purulent discharge or nasal blockage is rarely sinusitis; it is usually a primary headache, dental or jaw-joint pain.
What it is
Many patients arrive saying they have «sinusitis» because their face or forehead hurts. Rhinosinusitis causes facial pain or pressure, but almost always with purulent discharge and nasal blockage. Without those symptoms, think of other causes: primary headaches (migraine, tension-type headache, cluster headache), dental pain, temporomandibular disorder or trigeminal neuralgia. The approach avoids unnecessary antibiotics and imaging and looks for the orbital and intracranial complications of sinusitis, which are emergencies.
Key questions in the history
- Is there purulent discharge, blockage or loss of smell?
- What is the pain like: pressure, throbbing, stabbing, electric shock?
- How long does each episode last and what triggers it (chewing, touching the face, bending forward)?
- Nausea, photophobia, tearing or a runny nose on the same side?
- Toothache, teeth grinding, jaw clicking?
- Age over 50, jaw claudication or visual symptoms?
Causes and classification
- Sinus: acute rhinosinusitis (pain or pressure with purulent discharge and blockage) or chronic (over 12 weeks).
- Dental: caries or abscess; pain on biting or with cold.
- Temporomandibular: pain on chewing, limited mouth opening, joint noises.
- Neuropathic: trigeminal neuralgia (brief shock-like pain with trigger zones) and postherpetic neuralgia.
- Primary headaches: migraine, tension-type and cluster headache can be felt in the face.
- Others: giant cell arteritis and sinonasal tumours.
Step-by-step approach
- Ask about nasal symptoms: without purulent discharge or blockage, sinusitis is unlikely.
- Characterise the pain: duration, type, triggers and autonomic symptoms.
- Apply the criteria for bacterial rhinosinusitis: persistent, severe or worsening after improvement.
- Examine the teeth, temporomandibular joint, chewing muscles and facial sensation.
- Do not order routine sinus X-rays; keep CT for complications, chronic disease or surgery.
- If there is trigeminal sensory loss or neurological signs, order MRI.
Differential diagnosis of facial pain
| Cause | Type of pain | Key clue |
|---|---|---|
| Acute rhinosinusitis | Pressure over the sinus | Purulent discharge and blockage |
| Migraine | Throbbing, attacks lasting hours | Nausea, photophobia, history of similar attacks |
| Cluster headache | Very severe, around the eye | Tearing and runny nose on the same side |
| Trigeminal neuralgia | Shocks lasting seconds | Trigger zones on talking, eating or touching the face |
| Temporomandibular disorder | Dull, on chewing | Limited opening, clicking, teeth grinding |
| Dental pain | Localised, on biting or with cold | Caries or abscess |
Red flags
- Periorbital swelling or redness, proptosis, double vision, pain on eye movement or loss of vision.
- Severe headache, neck stiffness, reduced consciousness or focal signs.
- A soft frontal swelling in a patient with sinusitis.
- Facial pain with numbness, one-sided nosebleeds or progressive blockage.
- Over 50 with temporal headache, jaw claudication or visual symptoms.
Next step / Initial management
- Mild acute rhinosinusitis: pain relief and observation; if it meets bacterial criteria and is treated, amoxicillin or amoxicillin-clavulanate.
- Trigeminal neuralgia: carbamazepine is the first-line drug; routine referral to neurology.
- Temporomandibular disorder: local heat, a soft diet, analgesics and dental assessment.
- Orbital or intracranial complication of sinusitis: urgent same-day referral to the emergency department, with ENT and ophthalmology.
- Persistent facial pain without a clear cause, one-sided or with neurological symptoms: priority referral to ENT or neurology.
Test yourself
Think of the answer, then tap the question to see it.
A 30-year-old woman has repeated «sinusitis»: throbbing frontal pain for hours, nausea and photophobia, with no purulent discharge. What do you suspect?
Migraine. Without purulent discharge or nasal blockage, rhinosinusitis is unlikely; primary headaches are often mistaken for «sinus headache».
A 60-year-old man has electric shocks lasting seconds in the right cheek when chewing or shaving. Diagnosis and first-line treatment?
Trigeminal neuralgia (maxillary division); carbamazepine is first line. If there is sensory loss, order MRI.
A child with sinusitis develops eyelid swelling, proptosis and pain on eye movement. What do you do?
Suspect orbital cellulitis: urgent referral for CT, intravenous antibiotics and ENT and ophthalmology assessment.
When do you suspect acute bacterial rhinosinusitis?
If it lasts more than 10 days without improving, is severe from the start (high fever with purulent discharge) or worsens after initial improvement.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Acute Sinusitis (StatPearls Publishing (NCBI Bookshelf), 2025); Trigeminal Neuralgia (StatPearls Publishing (NCBI Bookshelf), 2024); Temporomandibular Syndrome (StatPearls Publishing (NCBI Bookshelf), 2023); Outpatient Clinical Care for Adults (Centers for Disease Control and Prevention (CDC), 2024).
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Representative model, for educational purposes only.