Facial Pain, Headache, & Migraine: What is the Difference?

Episode 261: Facial Pain, Headache, & Migraine: What is the Difference?

Lindsay Weitzel, PhD:
Hello everyone, and welcome to HeadWise, the videocast and podcast of the National Headache Foundation. I’m Dr. Lindsay Weitzel, and I have a history of chronic and daily migraine that began at the age of four. I’m excited to be here today with a repeat guest and headache medicine specialist Dr. Fred Cohen. Hi, Dr. Cohen, how are you doing today?

Fred Cohen, MD:
I’m well, thank you for having me again.

Lindsay Weitzel, PhD:
Thank you for being here. We love having Dr. Cohen on. We learn so much when he’s here. He’s also fun and entertaining. Let’s start talking to Dr. Cohen. We have a great topic today, one that’s interesting and confusing. We are going to talk about facial pain. So, facial pain can be confusing for us because when our faces hurt when we have migraine, other types of headache, what is what. We’re going to clarify a lot of things today. Dr. Cohen, let’s start with a question that might seem odd, but like I said, it’s on everyone’s mind. How do we draw the line between facial pain and headache when so many of us have pain in our face when we have head pain, whether it’s from migraine or another type of headache diagnosis?

Fred Cohen, MD:
Sure. I guess to simplify this, one is a symptom, the other is a condition. For instance, migraine is a condition. Headache is a symptom. Facial pain means it’s here. Headache means it’s here. It’s not a diagnosis. For instance, you can have facial pain that’s a migraine. Migraine is defined as a moderate to severe pain lasting four hours at least five times. There are individuals who have migraine. The pain is focused here but it’s a migraine. And so that’s why it’s not is this migraine versus facial pain. It’s first what’s the condition, migraine, tension headache, trigeminal neuralgia, and where’s the pain. Another example is trigeminal neuralgia which is a common facial pain. It could be as high up up here and it might not be a migraine. It could be up here as a headache. So again, when it comes to facial pain or headache, think of that as location, and then we got to get what’s the diagnosis.

Lindsay Weitzel, PhD:
So, what are some of the most common facial pain diagnoses?

Fred Cohen, MD:
I’ll start with trigeminal neuralgia which the name of it the trigeminal nerve is the innervation of our feeling of the face in your ears and forward. And neuralgia means like inflamed nerve. And that’s what a lot of people think they have. But I would say many people think they have that when it’s actually migraine. Trigeminal neuralgia presents as this shocking pain. It’s like, think of it like zaps like zap, zap, zap. They’re not long lasting. And they could be again, anywhere in the face, usually one sided. Historically, it’s related to like chewing or brushing your teeth, putting on makeup, shaving, etc. It doesn’t have to be. And while it can be both sides, it’s very uncommon. I always describe it, if your pain is constant versus like that shocking, it could be migraine or something else. But that’s probably something that comes up a lot.

TMD or TMJ disorders, temporal mandibular joint, which is right here, that’s a really common issue that comes up. It’s a pretty complex area. A lot could happen there. It could be the joint, it could be the muscle around it, nerves around it, people have issues opening their mouth. It’s a wide gambit, a very wide range.

Then we have some other more rare ones, like primary stabbing headache. Remember I was saying how trigeminal neuralgia was like very specific. Think of primary stabbing, the opposite. It bounces around. It can’t decide where it wants to be. That’s a really simple way of describing that. We have SUNCT and SUNA, which are these headaches that are sort of similar to trigeminal neuralgia, but they have a lot of what we call autonomic symptoms, so like tearing of your eyes, redness of your eyes, congestion, runny nose. And again, like I said, migraine can appear as facial pain. Migraine, everyone thinks it has to be behind your eye. It doesn’t. It could be anywhere in your head. It could be around your nose. It could be around your cheeks. So, migraine is also, I would say, a common facial pain diagnosis.

Lindsay Weitzel, PhD:
I have another question that’s related to this. Can you have both diagnoses? Can you have a diagnosis of migraine and a diagnosis of facial pain?

Fred Cohen, MD:
So yes, it can be you have two different kind of headaches and I’ve seen that. And again, that’s not something for you the patient, to figure out. That’s something for me the provider to figure out. So, it’s absolutely possible to have more than one headache type.

Lindsay Weitzel, PhD:
And this might sound silly, but is pain behind the eyes always a migraine symptom, or could that also be a facial pain symptom? I heard you bring that up. And we talk about that so often in our communities, so I just wanted you to delve into that a bit if you could.

Fred Cohen, MD:
Again, the location is not as much what I care about. It’s more the quality and duration. If someone’s telling me that they have quick zaps kind of pain behind their eyes, migraine doesn’t present like that. Migraine is again at least four hours continuous. If someone tells me I have a pain in my eye for a minute and it goes away, it could be SUNA, it could be SUNCT, it could be trigeminal neuralgia. Sure, it’s still there. So really the location is not the only the defining thing when it comes to these diagnoses.

Lindsay Weitzel, PhD:
Are facial pain problems usually treated with medications?

Fred Cohen, MD:
Absolutely. I mean, just like migraine and other headache disorders there’s a wide range of not just medications, lifestyle, supplements. I always address things like diet and nutrition, sleep, mood, all that stuff. It doesn’t matter what the condition is. When it comes to medications, yes, there are more meds specific for the kind of facial pain. For instance, trigeminal neuralgia is typically treated with something called carbamazepine or oxcarbazepine. SUNCT and SUNA is Lamictal (lamotrigine). Gabapentin could be used for primary stabbing headache. So, there are different therapies for those. Or if it’s migraine, we do the migraine treatments.

Lindsay Weitzel, PhD:
What about things like Botox and nerve blocks that we are so often using in headache medicine? Are those things also used for facial pain?

Fred Cohen, MD:
Yes, those are used, but off label. Botox does not have an indication for trigeminal neuralgia. But there have been reports and studies that came out suggesting that it can be a treatment. I have used it for patients of mine with trigeminal neuralgia with good effect. I wouldn’t call it first line because again, it’s not the indicated use. But yes, nerve blocks and Botox can be used. There is evidence of using it for kinds of facial pain.

Lindsay Weitzel, PhD:
Does facial pain sometimes require surgical treatment?

Fred Cohen, MD:
I get this asked a lot about surgery. There is a place for surgery. It’s not first line, because a rule of medicine is do no harm. We don’t want to do something invasive at first. I always want to do medications and other routes before going to surgery. Because while there is evidence for improving with surgery, we have more data in regards to medication, and surgery could have complications. It could have consequences. Again, it’s not a first line. If someone is failing multiple therapies, we’re not getting the effect we want, yes. I have sent to neurosurgery colleagues of mine for an opinion. And so sometimes surgery does have a place. But again, I don’t ever endorse it as the first line thing to do.

Lindsay Weitzel, PhD:
Is it usually headache specialists that take care of patients with facial pain? Or are there other types of healthcare providers that people are going to for this problem?

Fred Cohen, MD:
It is a wide range. I would say, because the full name of my fellowship, my board certification, is Headache Medicine and Facial Pain. So yes, we have specific certifications that like it’s all we do. There are other, like neurologists are trained to look at facial pain. You also have in dentistry, there is a separate boards, orofacial dentist specialists. So, these are dentists that have done additional training to treat that. I have several colleagues who I work with like that. I would say like there is like there’s more other kind of providers. I don’t want to say one’s better than the other. But what I like about it is it’s different schools of thought. It’s different, like it’s a very collaborative environment. There are Orofacial Pain dentists that I collaborate with a lot. It’s great to have their opinion. Because again, it’s a very shared area. So, there’s different kind of providers you can see about this.

Lindsay Weitzel, PhD:
This question might sound odd, but it’s popping into my head as someone that talks to a lot of people with migraine who might not get better after CGRP medications, or they say, gosh, this part got better, but that part didn’t. If you’re one of those people that got better with CGRP medicines, but you still have pain in your face, are CGRP medicines not helping facial pain? Or might those people be someone that had both those diagnoses for example?

Fred Cohen, MD:
A bit of a complex question, because the root of this is what’s causing migraine. Migraine is complicated. How many times have I said this on this podcast? You figure it out; you win the Nobel Prize of Medicine. We know there are several neuropeptides and neuroinflammation involved. We know CGRP, we know PACAP, substance P, VIP. We know all these neuromodulators, neuropeptides are involved. And my theory is they’re individuals. What do you tell someone with migraine that the CGRP drugs don’t help them? Is it migraine? It is, I just think your migraine presentation isn’t as heavily affected by CGRP as others. So just because CGRPs fail or don’t work completely doesn’t mean it’s different diagnoses. It just means that mechanism might not be the mechanism for you. And I’m very hopeful that we have now PACAP, very long acronym, don’t ask me to name it. PACAP is a neuropeptide we know also related to migraine. We have drugs in phase 2 and phase 3 trials right now. I hope they’re FDA approval and success, because then we have another avenue to go down.

Lindsay Weitzel, PhD:
Is there anything else you’d like to add to this episode on facial pain?

Fred Cohen, MD:
If your someone who suffers facial pain, see your provider. Whether that you go to your dentist first or PCP, just go to someone. Because again, it could be migraine. It could be a lot of things, and there’s definitely treatment for it. A lot of people just go, oh, it’s just whatever. It’s a normal thing. No, there are a lot of specialists for this, medication for this, and at least when you start somewhere it could guide you. I can’t tell you how many patients find me from their primary care, their neurologist, or even their dentist. It’s starting somewhere. The ball’s got to get rolling at some point. So, I encourage anyone who suffers from facial pain, there’s stuff we could do. Get out there.

Lindsay Weitzel, PhD:
Okay, great. Well, thank you so much for being here.

Fred Cohen, MD:
Thank you for having me.

Lindsay Weitzel, PhD:
And thank you everyone for tuning in. And please listen to our next episode of HeadWise. Bye bye.

This episode is for educational purposes only and is not intended to provide medical advice. Please consult your healthcare provider regarding your individual symptoms and treatment options.

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