Pain in the Eye: Deep and Behind-the-Eye Causes

Deep eye pain vs surface eye pain

Surface pain feels gritty, scratchy or burning and usually comes from dry eye, conjunctivitis, a scratch or a foreign body. That is covered on our eye pain symptom page. This page focuses on pain that feels deep inside the eye, behind it or in the socket, which has a different set of causes and is more often linked to headaches or to sight-threatening inflammation.

The eye and the tissues around it get their sensation from the first branch of the trigeminal nerve, which also supplies the forehead, sinuses and the coverings of the brain. That is why headaches and sinus problems are so often felt "behind the eye".

Headache-related causes

Migraine

Migraine often causes throbbing pain behind one eye or around the temple, lasting 4 to 72 hours, with nausea and sensitivity to light and sound. Some people have a visual aura before the headache.

Cluster headache

Cluster headache causes excruciating, stabbing or boring pain in and behind one eye, lasting 15 minutes to 3 hours, often at the same time each day for weeks. The eye on the same side waters and reddens, the eyelid may droop, and the nostril runs. People are restless during attacks.

Tension headache and eye strain

Pressure or tightness behind both eyes and across the forehead, often with tired eyes after screen work. Uncorrected vision problems contribute.

Sinus causes

Sinusitis causes pressure behind and between the eyes, in the cheeks and forehead, with a blocked nose, thick discharge and reduced smell. Pain is often worse bending forward. Swelling and redness of the eyelids with sinusitis can signal spread to the eye socket and needs urgent care.

Eye conditions that cause deep pain

Giant cell arteritis

Giant cell arteritis is inflammation of medium and large arteries in people over 50. It causes new headaches, scalp tenderness, jaw pain on chewing, tiredness and sometimes pain around the eye. It can cause sudden, permanent blindness if untreated, so it is treated with high-dose steroids as soon as it is suspected.

Other causes

• Shingles affecting the forehead and eye
• Inflammation of the eye socket tissues (orbital inflammatory disease) and thyroid eye disease
• Trigeminal neuralgia, causing electric shock-like stabs
• Rarely, aneurysms, carotid artery dissection or tumors

How doctors evaluate deep eye pain

An eye examination is the starting point:

• Visual acuity and color vision
• Pupil reactions, including the swinging flashlight test for optic nerve problems
• Eye movements and any pain or double vision on movement
• Slit lamp examination for inflammation in the front of the eye
• Eye pressure measurement (tonometry)
• Dilated examination of the retina and optic nerve

Further tests depend on findings: blood tests (ESR and CRP for giant cell arteritis, and tests for autoimmune or infectious causes of uveitis or scleritis), MRI of the brain and orbits for optic neuritis, CT for orbital cellulitis or sinus disease, and a temporal artery biopsy or ultrasound for giant cell arteritis.

Treatment by cause

• Migraine: pain relievers or triptans at onset, and preventive medicines for frequent attacks.
• Cluster headache: high-flow oxygen and triptan injections or nasal sprays for attacks, and preventive treatment during cluster periods.
• Sinusitis: saline rinses, steroid nasal sprays, and antibiotics only for bacterial cases.
• Uveitis: steroid eye drops and drops that dilate the pupil, prescribed and monitored by an eye doctor. Treating the underlying condition prevents recurrences.
• Acute angle-closure glaucoma: emergency eye drops and medicines to lower pressure, then laser iridotomy to make a new drainage path. The other eye is often treated too.
• Scleritis: oral anti-inflammatory medicines, steroids or immune-suppressing treatment.
• Optic neuritis: often improves on its own over weeks. High-dose IV steroids can speed recovery, and MRI assesses MS risk.
• Giant cell arteritis: immediate high-dose steroids, then a long tapering course, sometimes with tocilizumab.
• Orbital cellulitis: IV antibiotics in hospital, sometimes surgery.

Frequently asked questions

What causes pain behind the eye?

The most common causes are migraine, cluster headache, tension headache, eye strain and sinusitis. Less common but serious causes include optic neuritis, uveitis, scleritis, acute glaucoma and giant cell arteritis. Pain with changes in vision, a red eye or pain on moving the eye should be checked promptly.

Why does my eye hurt when I move it?

Pain on moving the eye is a classic sign of optic neuritis, especially with dim or blurred vision in that eye. It can also come from orbital cellulitis, scleritis or sinusitis. Eye movement pain with vision changes, fever or eyelid swelling needs urgent assessment.

Can sinus problems cause pain behind the eyes?

Yes. The sinuses sit beside and between the eyes, so sinusitis often causes pressure behind the eyes, worse when bending forward, with nasal congestion and discharge. Eyelid swelling, double vision or fever with sinus symptoms can mean infection has spread and needs urgent care.

Is pain behind the eye a sign of a brain tumor?

Rarely. Brain tumors seldom cause isolated eye pain. Headaches from tumors tend to be persistent and worsening, often worse in the morning, with vomiting, seizures or neurological changes. Most pain behind the eye is caused by migraine, cluster headache, sinusitis or eye strain.

What is the difference between eye pain and a migraine behind the eye?

Migraine pain behind the eye comes with headache, nausea and light and sound sensitivity, and the eye itself looks normal and vision returns to normal after the attack. Pain from an eye condition often comes with redness, persistent blurred vision or pain on eye movement and needs an eye examination.