Persistent idiopathic facial pain (PIFP) is a rare and poorly understood condition that causes daily facial pain without any identifiable cause. Because there is little high-quality scientific evidence to guide treatment, an international panel of 16 pain experts used a rigorous three-round Delphi consensus process to develop the first internationally agreed-upon recommendations for managing this condition. The experts reached consensus on 35 of 42 statements (83%), strongly emphasizing the importance of a multidisciplinary team approach, avoiding invasive dental and surgical procedures, and measuring treatment success primarily by improved quality of life rather than pain elimination alone.
Persistent idiopathic facial pain, also known by its older name "atypical facial pain," is a chronic pain condition that affects the face. It was formally renamed in the 3rd edition of the International Classification of Headache Disorders (ICHD) in 2018 and recognized in the first International Classification of Orofacial Pain (ICOP) in 2020.
The condition is defined as "persistent facial pain, with variable features, recurring daily for more than 2 hours per day for more than three months, in the absence of clinical neurological deficit or preceding causative event." In simple terms, patients have daily facial pain that lasts for months or years, and despite thorough testing, no medical or dental cause can be found.
PIFP is rare, with a lifetime prevalence of approximately 0.03%. To put that in perspective, only about 3 out of every 10,000 people will experience this condition during their lifetime. It should not be confused with persistent idiopathic dentoalveolar pain (PIDAP), which is pain perceived specifically within the teeth and gums (intraoral tissues). PIFP can only be diagnosed when no other condition can explain the pain.
The majority of patients with PIFP are women. They typically describe the pain as diffuse, dull, aching, or nagging — and importantly, the pain does not follow the distribution of any specific nerve in the face. This is a key clinical distinction from neuropathic pain conditions like trigeminal neuralgia, which affects specific nerve pathways. The pain can be both deep and superficial, and it is often described as refractory (difficult to treat) and persisting for many years.
Facial pain in general is very common. Orofacial pain (pain confined to the oral cavity and/or face) affects approximately 16–22% of the population, and it has a major impact on quality of life, often causing impaired sleep, mood disturbances, and considerable disability. Dental pain is the most common form of orofacial pain, followed by pain linked to temporomandibular disorders (TMD), which involve the jaw joint and chewing muscles.
The underlying cause of PIFP remains unknown. Researchers have suggested that the pain may involve a disproportionate response to a minor injury, and brain imaging studies point toward central sensitization — a process in which the central nervous system becomes overly sensitive to pain signals. PIFP may also be considered a nociplastic pain type, which arises from altered pain processing in the central nervous system rather than from identifiable tissue damage or nerve injury.
Despite these insights, there was previously no established protocol for managing PIFP. Many different treatments have been proposed, but the lack of high-quality randomized controlled trials (the gold standard of medical evidence) has made evidence-based treatment decisions extremely difficult. As with many chronic pain conditions, a multimodal approach — combining multiple treatment strategies — has been recommended, ideally delivered by an interdisciplinary or transdisciplinary team with a joint treatment plan.
In the absence of scientific evidence, healthcare providers must rely on clinical experience. The collective experience of many experts, summarized into a consensus, is considered more valuable than the experience of any single individual. This is exactly what this Delphi study set out to achieve: establishing international consensus-derived guidelines for the management of patients with PIFP.
The researchers used the classic Delphi consensus method, a well-established technique for gathering expert opinions. One of the key advantages of the Delphi method is that it maintains anonymity among experts, eliminating the social pressure and influence that can occur when people meet face-to-face. This allows participants to express their true opinions freely.
The study protocol was registered on Researchweb Region Uppsala and publicly presented in the Uppsala Public Dental Health Service's 2022 Odontology Research Report.
The Delphi process consisted of three rounds, all conducted in English:
A maximum of two reminders were sent to experts who did not respond to the web-based questionnaires. The response rate was 100% in all rounds — meaning every single expert completed every round of the study.
Consensus was defined as more than 80% agreement or disagreement among the experts, meaning at least 13 out of the 16 experts had to agree or disagree for consensus to be reached. A secondary threshold was also established: if 11–12 experts (68–75%) agreed or disagreed, consensus was not reached, but a majority opinion was considered to exist.
Eighteen international pain experts were invited to participate. An expert was defined as a researcher with identifiable peer-reviewed publications and at least 10 years of clinical experience in managing pain patients. The mean total number of peer-reviewed publications among the expert panel was 226 (range: 45–608).
Two experts declined due to time constraints, leaving 16 experts from 3 of the 6 WHO regions (the European Region, the Region of the Americas, and the Western Pacific Region). The panel spanned a remarkable range of specialties:
The experts came from 10 countries: Israel, Brazil, the UK, Canada, Japan, Sweden, Germany, Greece, the USA, and Switzerland. The panel included a mix of dentists and physicians, reflecting the interdisciplinary nature of facial pain care. The three lead authors (Erik Lindfors, Per Alstergren, and Torsten Gordh) did not participate as members of the expert panel to avoid influencing the results. Experts received no financial compensation, but were invited to serve as co-authors on the publication.
The results of the study were clear and striking. Of the 42 statements presented to the experts:
The findings emphasized two overarching themes: multidisciplinary collaboration and avoidance of invasive procedures. These two principles emerged as the cornerstone of PIFP management.
The experts reached consensus on a comprehensive, step-by-step diagnostic approach. This is crucial because PIFP is a diagnosis of exclusion — meaning every other possible cause of the pain must be ruled out before the diagnosis can be made.
The experts emphasized that several pieces of information in the patient's history and symptom report are important for diagnosing PIFP:
Several examination steps were considered essential by the expert panel:
The experts reached consensus on the following imaging approach:
The experts identified five major differential diagnoses that must be excluded in any patient with suspected PIFP:
In addition, the experts identified several other differential diagnoses of interest:
The experts strongly endorsed a multidisciplinary approach to treating PIFP. The investigation and examination of a patient with suspected PIFP should be multidisciplinary and include a dental examination to exclude dental pathology. If possible, a dentist specialized in orofacial pain should also be consulted. Important medical specialties in the multidisciplinary investigation include:
A physiotherapist specialized in head/neck pain is desirable if available.
Non-pharmacological treatments were strongly emphasized:
The experts reached consensus on a specific, step-by-step pharmacological treatment approach, which can be thought of as a ladder:
Critically, the experts agreed that opioids should in general be avoided in patients with PIFP. This is consistent with broader guidelines for chronic pain, which caution against opioids due to risks of dependence, tolerance, and limited long-term effectiveness. Pharmacological treatment should be used "if this option has not already been exhausted."
One of the strongest messages from this study is the harm that can come from unnecessary invasive procedures. The experts reached a clear consensus: invasive and irreversible dental and surgical procedures without a definite indication should be avoided due to the risk of increased pain and a deteriorated clinical situation.
Specifically, the following procedures should be avoided unless there is strong, definite evidence of a local cause or pathology:
This recommendation reflects the unfortunate reality that many PIFP patients undergo repeated dental procedures — often multiple extractions or root canals — in an attempt to relieve pain that ultimately has no dental cause. These procedures frequently make the pain worse and can lead to permanent changes in the mouth that create additional problems.
The experts agreed that follow-up should always be individualized, since it depends on numerous factors, including:
In general, follow-up visits should be more frequent at the beginning of the treatment regimen and should continue on a regular basis over a period decided by the leading specialist in joint agreement with the patient.
Because PIFP is a chronic condition, the experts emphasized that it is important for the patient to have a contact person (for example, the leading specialist) for when they need support, and that the complaints and concerns of the patient must be taken seriously.
Perhaps the most important philosophical shift in these guidelines is how treatment success is measured. The experts reached a clear consensus that:
Interestingly, the experts did not reach consensus on using specific pain intensity reduction thresholds as measures of treatment success. Statements proposing that a 30% pain reduction on a Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS) constitutes treatment success, or that a 50% pain reduction constitutes success, both failed to achieve consensus. This suggests that the experts view treatment success in PIFP as a more holistic concept than simply a number on a pain scale.
These international consensus guidelines represent a major step forward for patients with PIFP. For the first time, there is an internationally agreed-upon framework for how these patients should be evaluated and managed.
The key takeaways for patient care are:
It is important to understand the limitations of this study when interpreting its findings:
If you or a loved one has been diagnosed with persistent idiopathic facial pain, here is what these guidelines mean in practical terms:
These guidelines are not a guarantee of a specific outcome, but they represent the best collective thinking of 16 of the world's foremost experts in facial pain. They offer patients a roadmap toward better management — one that prioritizes safety, compassion, and the things that matter most to patients in their daily lives.
PIFP is a rare chronic pain condition causing daily facial pain for more than three months, with no identifiable medical or dental cause. It affects about 3 in 10,000 people, mostly women. The pain is often dull or aching and does not follow a specific nerve pathway.
PIFP is a diagnosis of exclusion. Doctors take a detailed history, perform dental, neurological, and sensory exams, and use imaging like dental X-rays, CT, or MRI to rule out other causes. Psychological assessment is also recommended. Five major conditions must be ruled out: neuropathic pain, dental pain, jaw joint pain, headaches, and cancer.
A multidisciplinary team approach is strongly recommended, including an orofacial pain dentist, neurologist, pain specialist, and psychologist. Non-drug treatments like patient education, cognitive behavioral therapy, and attention to sleep, exercise, and diet are considered very important. Medication may also be used, but invasive dental or surgical procedures should be avoided.
Yes. The expert consensus strongly advises avoiding invasive and irreversible dental and surgical procedures—such as root canals, tooth extractions, jaw surgery, or exploratory surgery—unless there is clear evidence of a local cause. These procedures can increase pain and worsen your condition. Always seek an orofacial pain specialist before considering such treatments.
Experts recommend a step-by-step approach. First-line are tricyclic antidepressants like amitriptyline or nortriptyline. If these are not tolerated, an SNRI such as duloxetine or venlafaxine may help. Gabapentin or pregabalin can be added or switched. Botulinum toxin injections are a third-line option. Opioids should generally be avoided.
Treatment success is measured primarily by improved quality of life and well-being, including return to daily activities like work and social life. Pain reduction to a tolerable level is also a goal, but complete pain elimination is not required. Experts did not agree on using specific pain scale reduction percentages to define success.
Seek a multidisciplinary team. Ask for referrals to an orofacial pain specialist and a pain management clinic. Be cautious about dental procedures, be patient with medication trials, and ask about cognitive behavioral therapy. Focus on quality-of-life goals. Avoid opioids unless a specialist prescribes them for short-term severe needs, and keep a designated contact person.
Original Article Title: Management of persistent idiopathic facial pain
DOI: 10.1177/03331024251399927
Authors: Erik Lindfors, Per Alstergren, Rafael Benoliel, Paulo Conti, Justin Durham, Jean-Paul Goulet, Osamu Komiyama, Thomas List, Arne May, Dimos-Dimitrios Mitsikostas, Donald R. Nixdorf, Maria Pigg, Tara Renton, Gunnar Skagerberg, Peter Svensson, Rolf-Detlef Treede, Jens Christoph Türp, Joanna M. Zakrzewska, and Torsten Gordh
Journal: Cephalalgia, 2025, Vol. 45(12), pages 1–17. Published by the International Headache Society.
DOI: 10.1177/03331024251399927
Date Received: 7 June 2025; Revised: 23 October 2025; Accepted: 24 October 2025
Study Registration: The study protocol was registered on Researchweb Region Uppsala and publicly presented in the Uppsala Public Dental Health Service's 2022 Odontology Research Report. The research was conducted under a Creative Commons Attribution 4.0 License.
This patient-friendly article is based on peer-reviewed research. It has been written to make the study's findings accessible to patients and their families, but it does not replace professional medical advice. Always consult a qualified healthcare provider about your specific condition and treatment options.
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