Facial Droop: Is It Bell's Palsy or a Stroke?

You catch your reflection while brushing your teeth and something looks off. One corner of your mouth hangs lower. When you rinse, water dribbles out of that side. Maybe your eye on that side won't close all the way.

Your first thought might be "Bell's palsy." Your second should be "or is this a stroke?" Both can make one side of the face droop, and from the outside they can look alike. The difference matters a lot, because one is an emergency where minutes count.

What is Bell's palsy, and how is a stroke different?

Bell's palsy is sudden weakness of the muscles on one side of the face, caused by a problem with the facial nerve itself. It usually develops over hours to a few days, and doctors only call it Bell's palsy once other causes have been ruled out. It is fairly common, affecting about 15 to 40 people per 100,000 each year, and most people recover.

A stroke happens when blood flow to part of the brain is blocked or a blood vessel bleeds. The facial droop comes from the brain, not the nerve in the face, and it often comes with other signs such as arm weakness or trouble speaking.

The forehead clue

Doctors look closely at the forehead. Here is why:

• Bell's palsy usually affects the whole half of the face. You may not be able to raise that eyebrow, wrinkle that side of your forehead or close that eye fully.
• A stroke in the brain usually leaves forehead movement working, because each side of the forehead gets signals from both sides of the brain. The droop is mostly in the lower face, around the mouth and cheek.

This is a useful clue for doctors, but it is not a safe way to sort things out at home. Some strokes, such as those in the brainstem, can cause the whole face to droop too, usually along with dizziness, nausea or other symptoms. A forehead that still moves should be treated as a stroke until a doctor says otherwise.

Warning signs to know

Signs that point toward stroke and need emergency care:

• Face drooping on one side, especially if your forehead still moves
• Weakness, heaviness or numbness in an arm or leg
• Slurred, jumbled or lost speech, or trouble understanding others
• Confusion
• Sudden blurred or double vision
• Sudden dizziness, loss of balance or trouble walking
• A sudden, severe headache

Signs that fit Bell's palsy more closely (but still need a same-day doctor visit):

• Weakness of the whole side of the face, including the forehead and eyelid
• Trouble closing one eye, or a dry or watering eye
• Drooling or food collecting in one cheek
• Changes in taste, or sounds seeming louder on one side
• No weakness in the arms or legs and normal speech

When to call 911 or see your doctor

Call 911 for any new facial droop that comes with arm or leg weakness, speech trouble, confusion, vision changes or loss of balance. Call 911 if you are not sure. Do not drive yourself, and do not wait to see if it gets better. Note the time it started.

If the droop is the only symptom and you are confident there are no other stroke signs, you still need to be seen by a doctor the same day, at the emergency department or an urgent appointment. Medical treatment for Bell's palsy works best when started within 72 hours. If your eye won't close, ask how to protect it from drying out. Questions about medication are best answered by your doctor or pharmacist.

See your doctor again if your face is not improving after about three weeks, or if you notice a rash around the ear, severe pain, weakness on both sides of the face, or any new symptoms.

Why your physiotherapist asks about this

Facial droop is not something a physiotherapist diagnoses, but we often see people with neck pain, headaches, jaw pain or dizziness, and we may be the first to notice a change. At VPC, if you mention facial weakness or we see it, we will:

• Ask when it started and whether it came on suddenly
• Check forehead, eye and mouth movement on both sides
• Check arm and leg strength, speech, sensation and balance
• Ask about recent illness, ear pain, rashes and other health conditions

If anything suggests a stroke, we call 911. If it looks more like Bell's palsy, we make sure you see a doctor that same day. We never treat facial droop first and ask questions later.

What physiotherapy can and can't do

Physiotherapy does not treat the cause of Bell's palsy or a stroke. Those need medical assessment and treatment first.

For Bell's palsy, many people recover on their own over weeks to months. For people with more severe or slow recovery, physiotherapy can help with gentle, specific facial exercises focused on control and symmetry, and with managing tightness or unwanted linked movements. The research on facial exercises is still limited, so we keep expectations honest and work with your doctor. After a stroke, physiotherapy is a key part of recovering strength, balance and movement.

Key takeaways

• A new facial droop is a stroke until proven otherwise. Call 911 if there are any other stroke signs, or if you are unsure.
• Bell's palsy usually affects the whole half of the face, including the forehead. Stroke usually spares the forehead.
• The forehead clue is for doctors, not for deciding at home whether to get help.
• Even suspected Bell's palsy needs a same-day medical visit, because treatment works best within 72 hours.
• Physiotherapy plays a support role in recovery after medical care.

For a refresher on stroke warning signs, read our post on recognizing the warning signs of stroke. If you are recovering from a stroke, learn more about our post-stroke rehabilitation.

Call: 905-669-1221

Visit: 398 Steeles Ave W #201, Thornhill, ON

Book online: vaughanphysiotherapy.com

Sources

Baugh, R., Basura, G., Ishii, L., Schwartz, S. R., et al. (2013). Clinical practice guideline summary: Bell's palsy. AAO-HNS Bulletin, November 2013, 34 to 42. https://www.entnet.org/sites/default/files/Bulletin_BellsExecSummary_Final_102313.pdf

Heart and Stroke Foundation of Canada. (n.d.). FAST signs of stroke... are there other signs? https://www.heartandstroke.ca/stroke/signs-of-stroke/fast-signs-of-stroke-are-there-other-signs

Hohman, M. H., Warner, M. J., & Varacallo, M. A. (2024). Bell palsy. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482290/

National Health Service. (n.d.). Bell's palsy. https://www.nhs.uk/conditions/bells-palsy/

This article is for general information and isn't medical advice. If you have any of the warning signs above, call 911 or contact your doctor right away.