Pain around and behind the eye: sinuses, a tooth or a headache?

The NHS writes that eye pain can be felt behind, in or around the eye, that it is common and usually nothing to worry about, but that it can sometimes be serious and need medical help. The same source recommends not trying to diagnose the cause yourself. There is a reason for this warning: pain felt around the eye can come from the eyelid, the surface of the eye, the inside of the eye, the tissues in the eye socket, the sinuses, the nerves and the teeth. The information below is to point you to the right doctor at the right speed; the diagnosis is made at the examination.

Sinusitis is the cause that comes to mind most often. The NHS lists among the main symptoms of sinusitis pain, swelling and tenderness in the cheeks, around the eyes or in the forehead, a blocked or runny nose, a reduced sense of smell and green or yellow nasal discharge; toothache is also among the symptoms of sinusitis. MSD Manuals writes that in sinusitis, eye or facial pain changes with the position of the head. In other words, pain that gets worse when you lean forward, comes with nasal symptoms and starts after a cold points towards sinusitis. The NHS states that sinusitis usually clears up on its own within 4 weeks.

But a large share of pain mistaken for sinus pain is migraine. In a study published in Archives of Internal Medicine, 2991 people with a history of sinus headache, either self-described or diagnosed by a doctor, who had not previously been diagnosed with migraine and had no signs of infection, were assessed; 88 percent met the criteria for migraine-type headache. The symptoms these patients reported most often were pressure in the sinus area, pain in the sinus area and a blocked nose. The authors write that with recurring headaches without fever or pus-like discharge, symptoms in the sinus area may be part of migraine. Participants were selected from people with a history of sinus headache and no signs of infection; this rate cannot be carried over directly to the general population, but it shows that migraine must be considered with recurring sinus pain.

Cluster headache is rare but distinctive. The NHS describes it as a sharp, burning or piercing pain, usually on one side of the head, around the eye; attacks last between 15 minutes and 3 hours, start and stop without warning, come at the same time of year or at certain times of day, and make the person so restless they cannot keep still. Redness and watering of the eye on the same side, a drooping and swollen eyelid, a smaller pupil, sweating on the face and a blocked or runny nose can come with it. The NHS writes that painkillers such as ibuprofen and paracetamol do not work for cluster headache.

The relationship with the teeth runs both ways. First, cluster headache and similar headaches can refer pain to the middle of the face and the teeth. In a retrospective study examining 33 cluster headache patients seen at a pain centre of the UCLA School of Dentistry, 14 patients (42 percent) had seen dentists and received ineffective dental or medicine treatment. A systematic review of 22 studies also lists migraine, trigeminal neuralgia, sinus infection, toothache and jaw joint problems among the most common wrong diagnoses in this group of headaches, and writes that this leads to unnecessary, sometimes invasive treatments. These studies are based on small, selected groups of patients; they show not how often it happens, but that the confusion is real.

The second direction is a real dental problem. The roots of the upper back teeth are very close to the floor of the sinus; an inflamed upper tooth can infect the sinus and cause sinusitis, and this pain can settle under the eye. We have covered this picture in detail on our page explaining that sinusitis can come from a tooth. Rarer but serious is infection spreading from a dental abscess reaching the area around the eye. The NHS says to go to A&E if, with a dental abscess, swelling or pain starts in the eye or there is a sudden problem with vision. MSD also writes that infection of the eye socket (orbital cellulitis) usually spreads from a sinus infection, but sometimes from a dental infection.

The eye's own diseases are the group that must not be missed. The NHS lists something in the eye or a scratch on its surface, conjunctivitis, dry eyes, infections linked to contact lenses, inflammation of the inner layer of the eye (uveitis) and glaucoma. MSD writes that with inflammation of the optic nerve (optic neuritis), the pain is usually mild and gets worse when you move the eye, while acute angle-closure glaucoma causes severe eye pain and redness. The NHS states that with sudden glaucoma there may be intense eye pain, a red eye, tenderness around the eye, rainbow-coloured rings around bright lights, blurred vision, nausea and vomiting and headache, and that this is an emergency.

There is one more warning. If a new, frequent and severe headache, tenderness in the temple or scalp, jaw pain when eating or talking and a vision problem come together, the NHS considers inflammation of the temple artery (temporal arteritis). The NHS writes that if untreated this can lead to stroke and blindness, that people with a vision problem should be assessed in a hospital eye department the same day, and that treatment is started before the diagnosis is confirmed. Our page on temple pain covers this subject in detail.

The first list is signs that make it more likely the pain is coming from the sinuses, a headache or a tooth; for these, a pharmacist, your GP (family doctor) or a dentist is a suitable place to start. If an item in the second list applies to you, do not wait.

The sequence deliberately starts with the possibilities that threaten the eye and the brain, then moves on to telling the sinuses, headache and the teeth apart.

1. 1

   First, vision and emergency signs

   If there is sudden onset, loss or blurring of vision, rings around lights, a very red eye, an eye pushed forward, pain when moving the eye, a drooping eyelid seen for the first time or unequal pupils, the assessment is done in A&E or eye casualty. Call 112 or ask someone to take you.

2. 2

   A description of the pain is taken

   MSD writes that doctors ask when the pain started, how severe it is, and whether looking in different directions or blinking makes it hurt. Whether the pain comes in attacks or is constant, how many minutes or hours it lasts, at what time of day it comes and whether it is one-sided narrow down the diagnosis considerably.

3. 3

   Eye examination

   Visual acuity, pupil reactions, eye movements and the front of the eye are examined; if needed, the pressure inside the eye is measured. MSD writes that the cause of eye pain can usually be identified at the examination.

4. 4

   Nose and sinus assessment

   You are asked about the colour of the nasal discharge, whether it is on one side or both, fever, and whether the pain changes with the position of the head. The NHS writes that with sinusitis that causes symptoms on only one side of the face, has not responded to treatment in 3 months or keeps coming back, you can be referred to an ear, nose and throat (ENT) specialist.

5. 5

   Identifying the type of headache

   The NHS states that there is no specific test for cluster headache, that the diagnosis is made from where the pain is, how often it comes and the symptoms that come with it, and that brain imaging may be requested if needed to rule out other causes. For both migraine and cluster headache, the NHS recommends keeping a headache diary to understand the triggers.

6. 6

   Checking the dental side

   If there is decay, a deep filling, a root-treated tooth or gum inflammation in the upper back teeth, the dentist checks with cold, tapping and bite tests and X-rays whether a tooth explains the pain. If no tooth reproduces the pain, the headache diagnosis should be reviewed before any procedure on a tooth that cannot be reversed.

There is no single treatment for pain around the eye; depending on the cause, your GP, an eye doctor, an ENT specialist, neurology or a dentist becomes involved.

Below are the wrong decisions often seen with this picture, and what they cost. We are writing this so that you can ask the right questions whichever doctor you see.

Times vary greatly with the cause. The sequence below is the usual course described by the NHS; the plan of the doctor who follows you up comes first.

1. A cluster headache attack

   The NHS writes that attacks last between 15 minutes and 3 hours, can come several times a day and can continue for weeks or months.

2. A migraine attack

   The NHS writes that attacks usually last between 4 hours and 3 days, and that early symptoms can start hours or 2 days before the headache.

3. Sinusitis

   The NHS writes that sinusitis usually clears up on its own within 4 weeks; a picture that has not improved in 3 weeks at home or in 7 days with treatment should be taken to a doctor.

4. Long-lasting or one-sided sinusitis

   The NHS writes that with sinusitis that continues despite 3 months of treatment, keeps coming back or causes symptoms on only one side of the face, you can be referred to an ENT specialist. With a one-sided picture that does not go away, it makes sense to have the upper teeth checked too.

We do not give a single figure here, because the assessment and treatment of pain around the eye take place in completely different departments depending on the cause. These are the items that determine the scope:

Which department becomes involved

An eye, ENT, neurology or dental examination; sometimes several together.

Need for imaging

A CT scan is requested when a sinus or eye socket infection is suspected, and brain imaging if needed for a headache.

Hospital admission

With an eye socket infection, admission is needed for antibiotics through a vein.

When the right diagnosis is made

Putting a headache down to a tooth can lead to ineffective dental procedures that cannot be reversed.