Pain Behind the Ear - What Causes That?

I've prepared a list of causes of pain behind the ear so you can work out what to do about it.

I assume you have no sign of ear, nose or throat disease.  These 17 different causes have been prepared from 2 major headache journals and a search of the PubMed database.

The causes are in order from most common to least common.

17 Causes of Pain Behind the Ear

Cervicogenic Headache

By far the most commone cause. This pain is referred up the back of the head from degenerative (arthritic-type) change in joints of the upper neck. The pain can be dull or occasionally shooting type. 
In younger people this sort of pain can occur without significant evidence of joint damage but can be due to stifness of the joints following minor trauma like a fall, or poor posture during hours of desk work or studying.

If you have this sort of pain treatment by a physiotherapist can be a very effective means of reducing the pain. 
Pain is often worse on wakening, and can spread through to the forehead or eye. 
It is not unusual for it to remain located just behind the ear.

This headache affects about 4% of the population, accounts for about 17% of severe headaches and is present in about 50% of people who have had neck injuries like whiplash.

Like all common headaches you should find out what you can do to get back in control of your pain.

Extracephalic Idiopathic Stabbing pains - Ice-pick Headache

These pains are classically found in the eye, but can occur in or behind the ear too. 
They are not provoked by movement or touch, and last seconds. Indomethacin can relieve cases with very frequent pain episodes. 
There is also a "split-second" variant called "epicrania fugax" - which is also benign, but the pain seems to take a "zig-zag" course through the head!

Ice-cream Headache / Cold-stimulus Headache

About 4% of people with ice-cream headache will experience their pain behind or in the ear. This type of headache is more common in people with a history of migraine.

Hemicrania Continua

This is a chronic daily one-sided headache that should respond to strong anti-inflammatory drugs such as Indomethacin. 
There are cases of a relatively localised pain behind the ear, although usually pain in Hemicrania is more widespread. 
It is also possible that people who describe Hemicrania Continua are actually experiencing referred pain from the cervical spine.

A trial of physiotherapy to perform upper cervical mobilisations may be beneficial. 
Most cases do not have an underlying cause identified

Red Ear Syndrome

Pain is often part of the Red Ear Syndrome, but some will have no pain and just reddening and warmth or burning of the ear. 
Pain is usually around the ear, so I've included in the list of pain behind the ear.

Primary Yawning Headache

Yawning can produce pain in the head, or behind the ear. 
The classic cause is an elongated styloid process, but there are cases described without any cause being found, and they are called Primary Yawning Headache.

Eagle's Syndrome

This used to be a "catch-all" diagnosis for unexplained throat or ear pain. 
The classic description of Eagle's Syndrome is pain in the throat which spreads to the ear and worsens with swallowing. 
This can be attributed to an elongated styloid process, although it is more convincing if the symptoms and elongated styloid are on one side only. 
However, to prove this requires removal of the styloid which is a drastic step.

Sometimes a local anaesthetic injection to the styloid area can be used a diagnostic test, and if positive might give more confidence that surgery could help.

Headache After Acoustic Neuroma Surgery

5/32 cases in one series had persistent pain behind the ear following acoustic neuroma surgery. 3/32 had pain in the ear canal itself. Anecdotally, these symptoms can respond to nerve block procedures or to standard neuropathic pain medications like gabapentin or amitriptyline

Glossopharyngeal Neuralgia

These are sudden sharp pains into the ear triggered by swallowing. Pains can last several seconds up to a few minutes. The pain is episodic unlike the more continuous pain of Eagle's Syndrome. 
On detailed questioning of people with glossopharyngeal neuralgia you may discover that sneezing, talking, or yawning will trigger neuralgic pain in the ear. 
Most of these cases do not have a serious cause, although "vascular loop compression" of the glossopharyngeal nerve by a tortuous artery (like the posterior inferior cerebellar artery) can be found.

Like all ear pains, a careful examination by an ENT / Otorhinolaryngology specialist is required to rule out sinister causes like a nasopharyngeal neoplasm. 
Arguably, Carbamazepine is the drug of choice in neuralgia of this type - again based on anecdote rather than direct research evidence.

Nervus Intermedius Neuralgia

This is another cause of persistent pains in the ear, which are sometimes described like a red hot poker in the ear. There is usually no cause found, but Carbamazepine could be tried.  Superior laryngeal nerve pain can also be felt under the earlobe.

Nummular Headache

This localised area of pain is typically just behind and above the ear. 
The skin of the scalp can be tender, and in some cases the hair thins out over the painful territory. 
Gabapentin or Amitriptyline could be used, as the pain is thought to have its origin in damage to cutaneous nerves of the scalp. 
There is one case in the literature of nummular headache seemingly caused by a meningioma. 
However, the vast majority of these cases do not have a seriious cause at all. 
Some recent cases suggest that reactivation of herpes zoster virus (shingles) could be the cause of this unusual headache.

SUNCT

5% (2/43) cases of Sudden Unilateral Neuralgiform headache with Conjunctival injection and Tears in one of the largest series had pain located in the Ear. 
Most of these people have pain in or around the eye. 
The syndrome is characteristic, but really rare and other than Lamotrigine few medications seem to offer any relief.

Incomplete Transverse Myelitis due to Multiple Sclerosis

A case of multiple sclerosis with pain radiating behind the ear is described. There was inflammation found in the C2 level of the spinal cord - the area that provides sensory nerves to behind the ear. Multiple sclerosis would be a very, very rare cause of pain behind the ear.

Neck-tongue Syndrome and C2 Nerve root pain

The C2 nerve root will cause pain to shot up to behind the ear. In neck-tongue syndrome, there is an abnormal sensation in the tongue as well.

Bells Palsy

Bells Palsy is paralysis of the facial nerve associated with herpes virus reactivation. 
Pain behind the ear is typical and can precede paralysis by a day or so. Sometimes the pain is very prominent and the facial weakness is mild. 
Facial paralysis and severe ear pain usually means that there is Herpes Zoster of the geniculate ganglion, called Ramsay-Hunt syndrome. There is a shingles rash in the ear canal. Antivirals and steroids can be given for Bells Palsy and Ramsay-Hunt Syndrome. 
There are a couple of cases reported of pain behind the ear at the time of the menstrual period in women with previous Bells Palsy.

Greater Auricular Neuralgia

This term has been used to describe pain in the territory of the greater auricular nerve ie pain behind the ear and below the ear. 
However, this territory matches the C2 territory and distinguishing this from ordinary cervicogenic headche can be difficult. Treatment is with standard neuropathic pain preparations like Gabapentin.

Carotid Artery Dissection

Pain from the Carotid artery (one of the main arteries in the neck) can produce pain behind the ear over the mastoid bone. One series of 21 cases found that 3 people had mostly pain behind the ear as a cause of their symptoms.  Usually the pain of carotid artery dissection is a sudden onset pain, and can follow neck trauma.

Pain during Carotid Artery Angioplasty

One series identified ear pain in 3 out of 49 people undergoing an angioplasty procedure to the carotid artery.

HeartMath: Inner Balance sensor for iOS

Angina or Heart Attack

There are cases of ear pain as the only symptom of heart disease.  However, this pain is usually located in front of the ear, not behind the ear.  Heart disease presenting as ear pain is sometimes called 'Cardiac Otalgia'.

As the most common cause of pain behind the ear is a neck-related problem, you should consider looking at what you can do to sort out your pain.

Pain in or around the ear can be difficult to diagnose, as the nerve supply of the ear is complicated.

There are many possible sources of pain behind the ear

The nerves that supply the area behind the ear are complicated and involves 5th (auriculotemporal), 7th (facial), 9th (glossopharyngeal) and 10th (vagus) cranial nerves.

The area behind the ear is mostly from the C2 and C3 nerves, so diseases of the upper part of neck and spinal cord can produce symptoms here.

In patients who attend me, pain referred from the cervical spine is by far the most common cause.

However, pain in the ear can come from almost anywhere in the head or neck.

The 10th cranial nerve supplies the back (posterior) half of the external ear canal - the bit that is open to the outside. (The Romans used to stimulate the ear with a feather to induce vomiting - this stimulated the vagus nerve which also controls the stomach and oesophagus!)

Pain behind the ear that is neurological in orgin, is often intermittent and shooting - called neuralgic pain.

If a nerve has been more permanently damaged, neuropathic pain can be burning or cold and often has a creepy or itchy quality to it.

More Information

6 Things You Must Know About Your Headaches

Go from Pain Behind the Ear to other Headache Locations

References

If there are no references listed, please notify me, as this box should contain a list of information sources, or a link to a 'Systematic Review' of the topic discussed on this page.

CJ Schankin et al. Headache Syndromes After Acoustic Neuroma Surgery and Their Implications for Quality of Life. Cephalalgia 2009 29: 760.

Kreiner M et al, Craniofacial pain as the sole symptom of cardiac ischemia: A prospective multicenter study.  JADA January 2007 138: 74-79.

C. M. Fisher.  The Headache and Pain of Spontaneous Carotid Dissection. Headache 22:60-65, 1982.

DE Jacome. Catamenial Synkinetic Retroauricular Pain. Cephalalgia 2003 23: 214.

CJ Boes et al. Chronic Paroxysmal Hemicrania Presenting as Otalgia With a Sensation of External Acoustic Meatus Obstruction: Two Cases and a Pathophysiologic Hypothesis. Headache 1998;38:787-79.

Montalbetti L et al.  Elongated styloid process and Eagle's syndrome. Cephalalgia 1995;15:80-93.

SB Graff-Radford. SUNCT Syndrome Responsive to Gabapentin (Neurontin). Cephalalgia 2000 20: 515

G. W. Bruyn. Glossopharyngeal Neuralgia. Cephalalgia 1983 3: 143

Maimone-Baronello M et al Great Auricular Neuralgia Headache 2003;43:1005-6

Sjaastad O and Spierings E. ''Hemicrania Continua'': Another Headache Absolutely Responsive to Indomethacin. Cephalalgia 1984;4:65.

HM Selekler et al. Prevalence And Clinical Characteristics of an Experimental Model of 'ice-cream headache' in Migraine and Episodic Tension-type Headache Patients. Cephalalgia 2004;24:293.

JH Shin et al. Paroxysmal Stabbing Headache in The Multiple Dermatomes of The Head and Neck. Cephalalgia 2007;27:1101.

Lorenzo De Santi et al. Clinical-Radiologic Heterogeneity of Occipital Neuralgiform Pain as Multiple Sclerosis Relapse. Headache 2009;49:304-7

A Guillem et al. Nummular Headache Secondary to An Intracranial Mass Lesion. Cephalalgia 2007;27:943