ConditionBrain & nerves
Atypical Facial Pain (Persistent Idiopathic Facial Pain)
Atypical facial pain, now usually called persistent idiopathic facial pain (PIFP), is a chronic, daily ache in the face that does not fit the pattern of other facial pain conditions and has no cause found on examination or scans. The pain is typically deep, dull or burning, often in the cheek or jaw on one side, and present most of the day. It is a diagnosis made after other causes are excluded. Treatment combines nerve-pain medicines, psychological therapies and avoiding unnecessary dental or surgical procedures.
Also called: Persistent idiopathic facial pain (PIFP), atypical facial neuralgia, chronic idiopathic facial pain
At a glance
- What it is
- Daily, persistent facial pain with no identifiable dental, sinus, nerve or structural cause.
- Typical pain
- Deep, dull, aching or burning, poorly localized, often in the cheek, jaw or near the nose.
- Who gets it
- Most often women aged 30 to 60; sometimes begins after dental or facial procedures.
- Diagnosis
- By exclusion, after dental, ENT and neurological assessment and usually MRI.
- Treatment
- Tricyclic antidepressants, SNRIs or anticonvulsants, CBT and avoiding further invasive procedures.
When to get help
Call 911 or go to the ER
- Sudden facial numbness or weakness with slurred speech, arm weakness or vision loss (possible stroke)
See a doctor within a day or two
- Facial pain with fever, facial swelling or swelling around the eye
- New facial pain with jaw pain on chewing, scalp tenderness or vision changes, especially over age 50
- Facial pain with new numbness, double vision, hearing loss or weakness of facial muscles
Book a routine appointment
- Facial pain present most days for more than 3 months
- Ongoing pain after dental work or facial surgery that has healed
- Facial pain with low mood, poor sleep or difficulty functioning
What atypical facial pain feels like
The International Classification of Headache Disorders defines PIFP as facial pain that:
- recurs daily for more than 2 hours a day, over more than 3 months
- is poorly localized and does not follow the distribution of a single nerve
- is dull, aching or nagging, rather than electric or shooting
- has a normal clinical neurological examination
- is not explained by a dental or other cause found on investigation
Many people describe a constant toothache-like or deep cheek pain that may spread to a wider area of the face or neck. It is usually on one side, but can be both. Stress and fatigue can make it worse. It does not typically wake people from sleep.
How it differs from other facial pain
| Condition | Typical pain |
|---|---|
| Atypical facial pain (PIFP) | Constant, dull, deep, poorly localized; no triggers |
| Trigeminal neuralgia | Brief electric-shock jabs lasting seconds, triggered by touch, chewing or talking |
| TMJ disorder | Jaw and ear-area pain with chewing, clicking and limited opening |
| Dental pain | Localized to a tooth, triggered by hot, cold or biting |
| Sinusitis | Pressure with nasal congestion and discharge, worse bending forward |
| Postherpetic neuralgia | Burning pain where shingles occurred |
| Burning mouth syndrome | Burning of the tongue, lips or mouth |
Some people with PIFP have features of a nerve injury, such as patchy numbness after dental surgery. This is now classed separately as post-traumatic trigeminal neuropathic pain.
Causes and risk factors
The cause is not known. Theories include changes in how the brain and nervous system process pain (central sensitization) and minor nerve injury. Factors linked with PIFP:
- female sex and middle age
- dental procedures such as root canals or extractions, or facial surgery, before onset in some people
- other chronic pain conditions, such as fibromyalgia and irritable bowel syndrome
- depression, anxiety and stress, which can be both a cause of worse pain and a result of it
Diagnosis
Because PIFP is a diagnosis of exclusion, other causes are ruled out first:
- Dental examination and X-rays.
- ENT assessment for sinus or nasal disease.
- Neurological examination for sensory loss or other nerve signs.
- MRI of the brain and face, often with attention to the trigeminal nerves, to exclude tumors, multiple sclerosis or blood vessel compression.
- Blood tests for inflammation in older adults, to exclude giant cell arteritis.
Repeated dental treatments or extractions in search of a cause are discouraged, because they often fail and can worsen pain.
Treatment
Treatment aims to reduce pain and improve function. Response varies, and a combination usually works best.
- Tricyclic antidepressants such as amitriptyline or nortriptyline at low doses, used for their pain-modulating effect rather than mood.
- SNRIs such as duloxetine or venlafaxine.
- Anticonvulsants such as gabapentin or pregabalin.
- Cognitive behavioral therapy and pain management programs, which have good evidence for chronic pain.
- Treatment of depression, anxiety and sleep problems.
- Other options: some people benefit from botulinum toxin injections, nerve blocks or neuromodulation, but evidence is limited.
Standard painkillers such as acetaminophen (paracetamol) and NSAIDs usually help little, and opioids are not recommended.
Outlook
PIFP is often long-lasting, but many people achieve meaningful pain reduction with treatment. Pain clinics and orofacial pain specialists offer coordinated care. Avoiding unnecessary procedures and addressing sleep, stress and mood improves quality of life.
Frequently asked questions
What causes atypical facial pain?
The exact cause is unknown. It is thought to involve altered pain processing in the nervous system, sometimes after minor nerve injury from dental work or facial surgery. Stress, depression and other chronic pain conditions are linked and can make it worse.
How is atypical facial pain diagnosed?
It is diagnosed when daily facial pain lasts more than 3 months and dental, sinus, nerve and other causes have been excluded through examination, X-rays and usually an MRI. The pain is typically constant, dull and poorly localized.
Is atypical facial pain the same as trigeminal neuralgia?
No. Trigeminal neuralgia causes brief, severe electric-shock pains triggered by touch or chewing. Atypical facial pain is a constant, dull or aching pain without triggers. They respond to different treatments, so the distinction matters.
Can atypical facial pain be cured?
There is no guaranteed cure, but many people get substantial relief from nerve-pain medicines such as amitriptyline, combined with CBT and treatment of sleep and mood problems. Symptoms sometimes ease over time.
Sources
This guide was written from current patient and clinical guidance, including:
- International Headache Society: International Classification of Headache Disorders, 3rd edition (ICHD-3), persistent idiopathic facial pain
- International Classification of Orofacial Pain (ICOP)
- American Academy of Orofacial Pain: Patient information
- NHS: Facial pain
- The Facial Pain Association: Atypical facial pain