First Bite Syndrome

Author: Courtney Misher, MPH, BS R.T.(T)
Last Reviewed: October 13, 2022

First bite syndrome is pain in your mouth from salivating (producing saliva, or liquid) or when you take the first few bites of your food. The pain can be described as intense, sharp, or like a muscle spasm. The pain is usually felt in the parotid (salivary gland) region, which is in the back of your mouth close to your ears. It is usually only felt on one side. The pain lessens with each bite but will return if there is a break in eating.

What causes it?

First bite syndrome can be a side effect of nerve damage during head and neck cancer surgery or from a head and neck tumor itself.

First bite syndrome can start anywhere from days, to months, to years later. This side effect can resolve on its own, but there are some treatments that can be helpful.

How is it treated?

There are a few ways to treat first bite syndrome, but each person may respond differently to the treatments.

  • Changes in behavior: Some actions, like rubbing your face, clenching your fists, and stomping your feet can distract from the pain. If the pain is only on one side of your mouth you can try chewing your food on the opposite side. You can also change your diet to avoid acidic and sour foods, which can stimulate more saliva production, causing more pain.
  • Medications: Research has shown that oral and topical pain medications, and non-steroidal anti-inflammatory medications, are not effective in treating first bite syndrome. Although some medications can help manage pain:
    • Carbamazepine, an anticonvulsant, has been shown to reduce how much pain you are in.
    • Amitriptyline, a tricyclic antidepressant, has been shown to reduce how long your pain lasts.
  • Radiation Therapy: Radiation is not commonly used to treat first bite syndrome but can be beneficial. There are risks associated with radiation that do not necessarily outweigh the benefits since first bite syndrome may resolve on its own.
  • Surgery: Total parotidectomy has been shown to completely resolve first bite syndrome but comes with many severe risks.
  • Botulinum Toxin Injection: Botulinum toxin (Botox) is a protein that blocks the release of acetylcholine. The injection is given into the painful area in the parotid gland. The number of injections varies from 1-3. The injections can be uncomfortable, but this is the only treatment that has been found to resolve symptoms in most cases. In rare cases, these injections can lead to facial nerve injury and xerostomia (dry mouth). Speak to your provider about how often these injections can be given.

First bite syndrome can affect your everyday life. Talk to your provider if you think you have first bite syndrome so together you can decide on a treatment plan.


Campbell, E. (2019, February 12). First bite syndrome: What every general dental practitioner should know. Scottish Dental magazine. Retrieved October 5, 2022, from

Laccourreye, O., Werner, A., Garcia, D., Malinvaud, D., Tran Ba Huy, P., & Bonfils, P. (2013). First bite syndrome. European annals of otorhinolaryngology, head and neck diseases, 130(5), 269–273.

Lee, B. J., Lee, J. C., Lee, Y. O., Wang, S. G., & Kim, H. J. (2009). Novel treatment of first bite syndrome using botulinum toxin type A. Head & neck, 31(8), 989–993.

Linkov, G., Morris, L. G., Shah, J. P., & Kraus, D. H. (2012). First bite syndrome: incidence, risk factors, treatment, and outcomes. The Laryngoscope, 122(8), 1773–1778.

Phillips, T. J., & Farquhar-Smith, W. P. (2009). Pharmacological treatment of a patient with first-bite syndrome. Anaesthesia, 64(1), 97–98.

Wemyss, C., Gibson, J., & Ryan, K. (2019). A case of idiopathic first bite syndrome responding to carbamazepine. Oral Surgery, 12(3), 243–247.


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