First Bite Syndrome: What Neurologists Need to Know

Curr Pain Headache Rep. 2021 Mar 24;25(5):31. doi: 10.1007/s11916-021-00950-7.


Purpose of review: Though first bite syndrome is well known in surgical settings, it is not commonly included in the differential for sharp paroxysmal facial pain in the neurology literature. This paper will highlight the clinical features and relevant anatomy of first bite syndrome, with the goal of helping clinicians differentiate this from other similar facial pain disorders.

Recent findings: First bite syndrome is severe sharp or cramping pain in the parotid region occurring with the first bite of each meal and improving with subsequent bites. Pathophysiology has been attributed to imbalanced sympathetic/parasympathetic innervation of the parotid gland. This is seen most typically in the post-surgical setting following surgery in the parotid or parapharyngeal region, but neoplastic etiologies have also been reported. It is common for patients to present with concurrent great auricular neuropathy and/or Horner's syndrome. Evidence regarding treatment is limited to case reports/series, however, botulinum toxin injections and neuropathic medicines have been helpful in select cases. It is critical for clinicians to be able to differentiate first bite syndrome from other paroxysmal facial pain. To help with this, we have proposed diagnostic criteria for clinical assessment. Patients often improve gradually over time, but symptomatic treatment with botulinum toxin or neuropathic medicine may be required.

Keywords: Facial pain; First bite; Great auricular; Head and neck surgery; Parotid; Trigeminal neuralgia.

Publication types

  • Review

MeSH terms

  • Acetylcholine Release Inhibitors / therapeutic use
  • Amitriptyline / analogs & derivatives
  • Amitriptyline / therapeutic use
  • Analgesics, Non-Narcotic / therapeutic use
  • Botulinum Toxins / therapeutic use
  • Carotid Body Tumor / surgery
  • Facial Pain / diagnosis*
  • Facial Pain / drug therapy
  • Facial Pain / etiology
  • Facial Pain / physiopathology
  • Head and Neck Neoplasms / complications
  • Head and Neck Neoplasms / surgery
  • Horner Syndrome / complications
  • Humans
  • Muscle Relaxants, Central / therapeutic use
  • Otorhinolaryngologic Surgical Procedures / adverse effects
  • Parapharyngeal Space
  • Parotid Gland / innervation
  • Parotid Neoplasms / complications
  • Postoperative Complications / diagnosis*
  • Postoperative Complications / drug therapy
  • Postoperative Complications / etiology
  • Postoperative Complications / physiopathology
  • Squamous Cell Carcinoma of Head and Neck / surgery
  • Tonsillar Neoplasms / surgery


  • Acetylcholine Release Inhibitors
  • Analgesics, Non-Narcotic
  • Muscle Relaxants, Central
  • Amitriptyline
  • cyclobenzaprine
  • Botulinum Toxins