Chronic Headache and Facial Pain
Chronic or recurrent headache and facial pain are not a single condition. Migraine, chronic tension-type headache, cluster headache, new daily persistent headache, temporomandibular disorders and trigeminal neuralgia can produce overlapping symptoms, but they have different diagnostic features and may require very different treatments.
In headache medicine, the term chronic often refers to headache occurring on at least 15 days per month for more than three months, although the definition varies between conditions. A person may also have more than one headache or facial pain disorder at the same time.
Headache disorders affect approximately 40% of the global population and can substantially disrupt sleep, concentration, employment, relationships and quality of life. Migraine is among the leading neurological causes of disability worldwide. Accurate diagnosis is therefore important: a treatment that is useful for migraine may be ineffective or inappropriate for cluster headache, a jaw disorder or a secondary headache caused by another medical condition.[1–3]
When Does a Headache Need Urgent Assessment?
Most recurrent headaches are not caused by a dangerous disease. However, some symptoms require urgent medical assessment.
Call triple zero (000) or attend an emergency department for:
a sudden, severe headache, particularly one that reaches maximum intensity within seconds or minutes
headache accompanied by new weakness, numbness, confusion, collapse, loss of consciousness or a seizure
headache with fever and neck stiffness
new loss of vision, persistent double vision or marked loss of balance
severe headache with repeated vomiting or a major change in behaviour
severe or worsening headache after a significant head injury.
Prompt medical review is also appropriate for a new or progressively worsening headache, a headache that is clearly different from a person’s usual pattern, or a new headache during pregnancy or after childbirth. Other reasons for urgent review of headache include a history of cancer, immune suppression, onset after the age of 50, or headache consistently triggered by coughing, straining, exertion or changes in posture.[3,4]
How Are Headache and Facial Pain Diagnosed?
Diagnosis is based mainly on a careful history and examination. Important features include:
when the symptoms began and how quickly they developed
the location, quality and duration of the pain
the number of headache days and individual attacks
associated symptoms, such as nausea, light sensitivity, visual disturbance, tearing or nasal congestion
triggers and aggravating factors
use of acute headache medicines
dental, jaw, neck, neurological and other medical symptoms
the effect on daily activities and function.
A headache diary maintained for several weeks can help distinguish headache types and measure whether treatment is working. It can record headache days, severity, associated symptoms, medicines used and the effect on work or normal activities.
Brain imaging is not routinely required merely for reassurance when symptoms are typical of a primary headache disorder, and the neurological examination is normal. Imaging or other investigations may be needed when warning signs, an abnormal examination or an unusual pattern suggests a secondary cause.[3,4]
Migraine: Episodic and Chronic
Migraine is a neurological disorder rather than simply a “bad headache” or a disorder of blood vessels. It involves altered sensory processing and activation of trigeminovascular pain pathways. Calcitonin gene-related peptide, usually abbreviated to CGRP, is one of several signalling molecules involved.[1,5–7]
Migraine is commonly described as:
episodic migraine: headache on fewer than 15 days per month
chronic migraine: headache on at least 15 days per month for more than three months, with migraine features on at least eight days per month.
Common Symptoms
A migraine attack may include:
moderate to severe headache, often but not always on one side
pulsating or throbbing pain
worsening with normal physical activity
nausea or vomiting
sensitivity to light, sound or smells
neck discomfort, fatigue, difficulty concentrating or mood changes before or after the headache.
Untreated attacks typically last 4 to 72 hours, though duration and symptoms vary.
Some people experience migraine aura. Aura consists of fully reversible neurological symptoms, most commonly visual changes such as zigzag lines, flashing lights or a blind spot. Sensory, language, and other neurological symptoms can also occur, although more rarely. Typical aura develops gradually and usually lasts between 5 and 60 minutes.
A first episode of aura, or symptoms involving weakness, loss of consciousness, persistent double vision, symptoms in only one eye or significant loss of balance, requires medical assessment rather than being assumed to be migraine.[1,3]
Triggers and Persistence
People may report attacks following changes in sleep, missed meals, dehydration, hormonal fluctuations, alcohol, stress or the period after stress has passed. Triggers vary considerably and are not the underlying cause of migraine.
Keeping regular sleep, meal and activity patterns is generally more useful than following a highly restrictive diet or attempting to avoid every possible trigger. The progression from episodic to chronic migraine is multifactorial. Frequent use of acute medicines, poor sleep and other physical or psychological health problems may contribute in some people, but no single factor explains every case.[2,5–8]
Management
Acute treatment aims to reduce the impact of an individual attack. Depending on medical history and contraindications, options may include:
paracetamol or a non-steroidal anti-inflammatory drug
a triptan, sometimes combined with paracetamol or an anti-inflammatory medicine
an anti-nausea medicine
a CGRP receptor antagonist, known as a gepant, in selected circumstances.
The choice of treatment and route of administration should reflect the severity of migraine and nausea, prior response, cardiovascular status, pregnancy considerations, and medication availability. Opioids are generally not recommended for routine treatment of migraine as they can contribute to heightened pain severity, especially with frequent use.
Preventive treatment may be considered when attacks are frequent, prolonged, or disabling, or when acute treatment is ineffective, unsuitable, or used too frequently. Options include medicines such as propranolol, topiramate, amitriptyline or candesartan; CGRP-targeted medicines; and onabotulinumtoxinA (Botox) for appropriately diagnosed chronic migraine. Selected non-invasive neuromodulation devices may also be considered.
No preventive treatment works for everyone. Choice should take account of other medical conditions, possible adverse effects, pregnancy or pregnancy planning, cost and personal preference. An adequate trial should be monitored with a headache diary before deciding whether treatment has been unsuccessful.[3,5–8]
Medication-Overuse (or Medication Adaptation) Headache
Medication-overuse headache, now called Medication Adaptation headache, can develop when medicines intended to treat attacks are used frequently over several months. It commonly occurs alongside migraine or tension-type headache rather than replacing the underlying diagnosis.
It should be considered when a person has headache on at least 15 days per month and, for more than three months, uses:
triptans, opioids, ergot medicines or combination pain medicines on at least 10 days per month; or
paracetamol, aspirin or non-steroidal anti-inflammatory medicines on at least 15 days per month.
These are diagnostic thresholds, not recommended “safe limits” for regular medicine use.
Management usually involves education, reducing or withdrawing the overused medicine, and establishing a more effective acute and preventive plan. Headache may temporarily worsen during withdrawal. People regularly taking opioids, or those with significant medical or psychological comorbidity, may require a supervised and more gradual plan.[1,3]
Chronic Tension-Type Headache
Chronic tension-type headache occurs on at least 15 days per month for more than three months. Despite its name, it should not automatically be attributed to emotional tension or “tight muscles.” Tenderness in the muscles around the head and neck may contribute, while altered pain processing may become more important when the headache is persistent.
Common Symptoms
Typical features include:
pain on both sides of the head
a pressing or tightening rather than pulsating quality
mild to moderate intensity
little or no aggravation from walking or other routine activity
no vomiting and fewer prominent migraine symptoms.
People with frequent headache and substantial nausea, light sensitivity or activity-related worsening may fit chronic migraine more closely, although the two disorders can coexist.[1]
Management
Occasional attacks may be treated with paracetamol or an anti-inflammatory medicine when medically appropriate. Opioids are not recommended, and frequent use of any acute medicine may contribute to medication-overuse headache.
For chronic tension-type headache, options may include:
a preventive medicine such as amitriptyline
a time-limited course of acupuncture
physiotherapy when neck or musculoskeletal factors are relevant
regular aerobic or strengthening exercise
strategies addressing sleep, stress and persistent muscle guarding.
Botulinum toxin injections are not an established preventive treatment for chronic tension-type headache.[3,8]
Cluster Headache
Cluster headache is an uncommon but highly disabling primary headache disorder. It usually occurs in bouts or “clusters” lasting weeks or months, separated by periods of remission. A smaller group has chronic cluster headache, in which remission is absent or brief.
Common Symptoms
Attacks typically involve:
very severe pain around or behind one eye or in the temple
pain strictly on one side during an attack
attacks lasting 15 to 180 minutes when untreated
attacks occurring from once every other day to as often as eight times per day
tearing, eye redness, nasal congestion, a runny nose, eyelid swelling or drooping on the painful side
marked restlessness or agitation.
Unlike many people with migraine, who prefer to remain still in a dark room, people experiencing cluster headache are often unable to keep still. Suspected cluster headache warrants medical assessment and usually specialist involvement.
Management
Because attacks escalate rapidly, oral pain medicines are usually too slow. Guideline-supported acute treatments include:
100% oxygen delivered through appropriate equipment at a high flow rate
subcutaneous sumatriptan
an appropriate nasal triptan when injections are unsuitable.
Verapamil is commonly used as a preventive treatment, but dose escalation requires medical supervision and electrocardiogram monitoring because it can affect heart conduction. A short corticosteroid course or a suboccipital corticosteroid injection may sometimes be used as transitional treatment while a preventive medicine takes effect. Other specialist treatments such as lithium require careful assessment and ongoing monitoring.
Treatment should not be delayed by assuming that the attacks are simply an unusually severe form of migraine.[3,9]
New Daily Persistent Headache
New daily persistent headache, or NDPH, is distinguished by its onset rather than by one particular type of pain.
A person can usually remember the day, or a very narrow period, when the headache began. The headache becomes continuous and unremitting within 24 hours and persists for more than three months. It may resemble migraine, tension-type headache or a mixture of both.
Some people recall a viral illness, stressful event or surgery around the time of onset, but this does not establish the cause. Before diagnosing NDPH, clinicians need to consider secondary causes such as a cerebrospinal-fluid pressure disorder, vascular disease, infection, medication effect or another neurological condition.
There is no single specifically approved or consistently effective treatment for NDPH. Treatment is often based on the headache phenotype it most closely resembles, while also addressing medication overuse, sleep, physical conditioning and associated symptoms. Preventive medicines or selected nerve blocks may be trialled, but the supporting evidence is limited and outcomes are variable.[1,10]
Temporomandibular Disorders
Temporomandibular disorders, or TMDs, are a group of more than 30 conditions involving the jaw joints, the muscles used for chewing, or both. Some TMDs can produce pain in the temple, face, ear region, jaw or neck and may coexist with migraine or other headaches.
Common Symptoms
Symptoms may include:
pain in the jaw joint or chewing muscles
pain made worse by chewing, clenching or wide mouth opening
jaw stiffness or restricted movement
locking of the jaw
painful clicking, popping or grinding
pain spreading into the temple, face or neck.
Painless clicking or popping is common and generally does not require treatment. Evidence also does not support the common assumption that an abnormal dental bite is the cause of most TMDs.
Management
Initial treatment should usually be conservative and reversible. Depending on the specific problem, this may include:
temporarily modifying hard or chewy foods during a flare
reducing gum chewing, nail biting and prolonged jaw clenching
heat or cold followed by gentle jaw exercises
physiotherapy or manual therapy
short-term anti-inflammatory medicine when medically appropriate
self-management, relaxation, cognitive behavioural therapy or biofeedback when persistent pain and muscle guarding are present.
A dental splint may protect teeth or help with habit awareness in selected people, but evidence that splints consistently reduce TMD pain is limited. A splint should not be designed to permanently alter the bite, and it should be reviewed if it increases pain.
Botulinum toxin has mixed evidence for TMD and should not be presented as a routine or reliably effective treatment, although some patients report sustained symptomatic benefit after Botox injections, which may need to be repeated. Arthrocentesis may be considered for selected intra-articular disorders, such as some cases involving disc displacement and restricted opening, but outcomes vary. Permanent bite alteration, open surgery or joint replacement should generally be reserved for clearly defined structural disease after simpler treatments have been considered.[11,12]
Trigeminal Neuralgia
Trigeminal neuralgia is an important cause of facial pain that is sometimes mistaken for dental pain, TMD or migraine.
It typically causes brief, severe, electric-shock-like pain on one side of the face. Attacks may be triggered by light touch, talking, chewing, tooth brushing, washing the face or exposure to wind. Individual bursts usually last from a fraction of a second to around two minutes, although they may recur many times. Some people also develop a more continuous background ache.
Medical assessment is needed to confirm the diagnosis and exclude secondary causes. Brain magnetic resonance imaging is generally recommended as part of the assessment.
Carbamazepine or oxcarbazepine is usually considered first-line treatment. These medicines require review for adverse effects, interactions and, in some circumstances, blood-test monitoring. When medication is ineffective or poorly tolerated, specialist surgical or percutaneous treatments may be considered. These options differ in durability and in risks such as facial numbness, altered corneal sensation or other nerve injury.[13]
Sleep, Mood, Stress and Overlapping Pain
Poor sleep, stress, depression, anxiety and trauma-related symptoms can increase headache-related distress and disability. Conversely, recurrent severe pain can disrupt sleep, reduce activity, affect relationships and contribute to emotional symptoms.
Recognising these interactions does not mean the pain is imagined or “just psychological.” Treatment of insomnia, mood symptoms, fear, avoidance and unhelpful coping patterns may improve function and reduce the overall burden of pain, even when a neurological or musculoskeletal diagnosis is well established.
Multidisciplinary care may be particularly useful when a person has several overlapping diagnoses, medication overuse, major sleep disturbance, loss of physical conditioning, substantial work disability or persistent psychological distress.[2,11]
Where Do Interventional Procedures Fit?
Interventional treatments are not interchangeable. Their role depends on the diagnosis, previous treatments and the quality of evidence for the particular condition. A temporary response to a local anaesthetic block may be clinically informative, and can be used to guide further treatment, but it does not by itself prove the source of all symptoms or guarantee a lasting response to another procedure.
OnabotulinumtoxinA for Chronic Migraine
OnabotulinumtoxinA (Botox) is a guideline-supported preventive treatment for appropriately diagnosed chronic migraine. It is administered according to a standardised injection protocol and generally requires repeated treatment to assess and maintain benefit. In Australia, only Specialist Neurologists can administer Botox under Medicare; all other indications are not approved uses.
It should not be extrapolated to all headache or facial pain conditions. Botulinum toxin is not an established preventive treatment for chronic tension-type headache, and its effectiveness for TMD remains uncertain.[3,7,8,11]
Occipital Nerve Blocks
A greater occipital nerve block involves injecting local anaesthetic, sometimes with corticosteroid, near the nerve at the back of the head. It may be used as a short-term adjunct in selected people with migraine, cluster headache or occipital neuralgia. A suboccipital corticosteroid injection may also be used as transitional treatment in cluster headache.
Response and duration vary. Current evidence does not support promising a particular percentage of pain relief, a fixed duration of benefit or routine monthly blocks for all people with migraine, tension-type headache or NDPH. Evidence is insufficient to establish greater occipital nerve blocks as routine long-term prevention for chronic migraine.[8,9,14]
Nevertheless, some patients may report significant benefit for reduction in pain severity and frequency, reduced medication use and improved function.
Sphenopalatine Ganglion and Peripheral Trigeminal Blocks
Sphenopalatine ganglion blocks and blocks of supraorbital, infraorbital or other trigeminal branches have been studied for several headache and facial pain conditions. However, diagnoses, techniques and outcomes vary substantially, and much of the literature consists of small or unreplicated studies.
These procedures may be considered in selected specialist settings.[8,15]
Radiofrequency Procedures
Pulsed radiofrequency and thermal radiofrequency are different techniques. Pulsed radiofrequency is intended to alter nerve signalling without creating the same degree of thermal lesion, whereas thermal radiofrequency deliberately ablates targeted nerve tissue.
Evidence for pulsed radiofrequency of the occipital nerves, upper cervical nerves or sphenopalatine ganglion remains heterogeneous and generally of low certainty. It does not support a general claim that people can expect six to twelve months of relief. Current guidelines find insufficient evidence to recommend pulsed radiofrequency of upper cervical nerves or sphenopalatine ganglion treatment routinely for chronic migraine.[8,16]
Destructive procedures involving trigeminal pathways have a separate and more established role in carefully selected, medication-refractory trigeminal neuralgia. They are not routine treatments for migraine, TMD or unexplained facial pain and require discussion of potentially significant sensory complications.[13]
If patients have failed multiple conservative strategies and have responded to a diagnostic block, radiofrequency neurotomies may be considered.
TMD Procedures
Botulinum toxin, joint corticosteroid or hyaluronic-acid injections, prolotherapy and arthrocentesis should not be grouped together as universally effective treatments for TMD. Evidence varies according to the precise joint or muscle disorder.
Arthrocentesis may help some people with a displaced joint disc and restricted opening, but research findings and individual outcomes are inconsistent. Botulinum toxin studies have produced mixed results. More invasive treatment should follow a specific diagnosis and a discussion of conservative alternatives, uncertainties and procedure-related risks.[11,12]
Neuromodulation
Some non-invasive neuromodulation devices have an expanding evidence base for the acute or preventive treatment of migraine, and non-invasive vagus nerve stimulation may be considered for episodic cluster headache. Availability, cost and regulatory approval vary between jurisdictions.[7,8]
Implanted occipital nerve or sphenopalatine ganglion stimulation requires surgery and implanted hardware. It is not routine treatment for migraine or cluster headache and should be restricted to highly selected, medically refractory cases managed in specialist centres. Potential complications include infection, lead movement or breakage, discomfort and further operations. Evidence is less certain than for established pharmacological treatments, and no single response percentage applies across devices, diagnoses and study populations.[8,17,18] There is limited evidence for transcutaneous non-invasive vagus nerve stimulation and transcranial magnetic stimulation.
Principles of Long-Term Management
An individual treatment plan may combine:
education and a clear working diagnosis
a headache diary and measurable treatment goals
an acute treatment plan that limits medication overuse
preventive treatment when attacks are frequent or disabling
regular sleep, meals, hydration and physical activity
physiotherapy or jaw rehabilitation where relevant
management of sleep, mood and stress-related difficulties
periodic review of effectiveness, adverse effects and ongoing need.
The aim is not always complete elimination of pain. Meaningful goals may include fewer headache days, shorter or less severe attacks, reduced reliance on acute medication, improved participation in work and family life, and greater confidence in managing future episodes.
No treatment is effective for everyone. A change in headache pattern, new neurological symptoms or progressive deterioration should prompt reassessment rather than simply repeating the existing treatment.[3,5–9]
General information only:
This article provides general education and is not a substitute for individual medical, neurological or dental assessment. Medicines and procedures have contraindications and potential adverse effects. Seek urgent assistance for the warning signs described above.
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