Supraorbital Neuralgia

Supraorbital Neuralgia

Clinical Syndrome

The pain of supraorbital neuralgia is characterized as persistent pain in the supraorbital region and forehead with occasional sudden, shock-like paresthesias in the distribution of the supraorbital nerves.

Sinus headache involving the frontal sinuses, which is much more common than supraorbital neuralgia, can mimic the pain of supraorbital neuralgia.

Supraorbital neuralgia is the result of compression or trauma of the supraorbital nerves as the nerves exit the supraorbital foramen.

Such trauma can be in the form of blunt trauma directly to the nerve, such as when the forehead hits the steering wheel during a motor vehicle accident, or repetitive microtrauma resulting from wearing welding or swim goggles that are too tight. This clinical syndrome also is known as swimmer’s headache.

What are the Symptoms of Supraorbital Neuralgia

The supraorbital nerve arises from fibers of the frontal nerve, which is the largest branch of the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital fissure and passes anteriorly beneath the periosteum of the roof of the orbit.

The frontal nerve gives off a larger lateral branch, the supraorbital nerve, and a smaller medial branch, the supratrochlear nerve. Both exit the orbit anteriorly.

The supraorbital nerve sends fibers all the way to the vertex of the scalp and provides sensory innervation to the forehead, upper eyelid, and anterior scalp.

The pain of supraorbital neuralgia is characterized as persistent pain in the supraorbital region and forehead with occasional sudden, shock-like paresthesias in the distribution of the supraorbital nerves.

Occasionally, a patient suffering from supraorbital neuralgia complains that the hair on the front of the head hurts.

Supraorbital nerve block is useful in the diagnosis and treatment of supraorbital neuralgia.

How is this diagnosed?

Magnetic resonance imaging (MRI) of the brain provides the best information regarding the cranial vault and its contents.

MRI is highly accurate and helps identify abnormalities that may put the patient at risk for neurological disasters secondary to intracranial and brainstem pathological conditions, including tumors and demyelinating disease.

Magnetic resonance angiography (MRA) also may be useful in helping identify aneurysms, which may be responsible for the patient’s neurological findings.

In patients who cannot undergo MRI, such as a patient with a pacemaker, computed tomography (CT) is a reasonable second choice. Radionuclide bone scan, CT, and plain radiography are indicated if sinus disease, fracture, or bony abnormality such as metastatic disease is considered in the differential diagnosis.

Screening laboratory tests consisting of complete blood cell count, erythrocyte sedimentation rate, and automated blood chemistry testing should be performed if the diagnosis of supraorbital neuralgia is in question. Intraocular pressure should be measured if glaucoma is suspected.

Differential Diagnosis

Supraorbital neuralgia is a clinical diagnosis supported by a combination of clinical history, normal physical examination, radiography, CT, and MRI.

Pain syndromes that may mimic supraorbital neuralgia include ice pick headache, trigeminal neuralgia involving the first division of the trigeminal nerve, demyelinating disease, and chronic paroxysmal hemicrania.

Trigeminal neuralgia involving the first division of the trigeminal nerve is uncommon and is characterized by trigger areas and tic-like movements.

Demyelinating disease is generally associated with other neurological findings, including optic neuritis and other motor and sensory abnormalities.

The pain of chronic paroxysmal hemicrania lasts much longer than the paroxysmal pain of supraorbital neuralgia and is associated with redness and watering of the ipsilateral eye.

How is this treated?

The primary treatment intervention for supraorbital neuralgia is the identification and removal of anything causing compression of the supraorbital nerves (e.g., tight welding or swim goggles).

A brief trial of simple analgesics alone or in combination with gabapentin also should be considered.

For patients who do not respond to these treatments, supraorbital nerve block with local anesthetic and a steroid is a reasonable next step.

Ultrasound guidance for needle placement may be useful when performing supraorbital nerve block.

To perform supraorbital nerve block, the patient is placed in the supine position. Using a 10-mL sterile syringe, 3 mL of local anesthetic is drawn up.

When treating supraorbital neuralgia with supraorbital nerve block, 80 mg of depot steroid is added to the local anesthetic with the first block, and 40 mg of depot steroid is added with subsequent blocks.

The supraorbital notch on the affected side is identified by palpation. The skin overlying the notch is prepared with antiseptic solution, with care taken to avoid spillage into the eye. A 25-gauge, 1½-inch needle is inserted at the level of the supraorbital notch and is advanced medially approximately 15 degrees off the perpendicular to avoid entering the foramen.

The needle is advanced until it approaches the periosteum of the underlying bone. A paresthesia may be elicited, and the patient should be warned of such. The needle should not enter the supraorbital foramen; if this occurs, the needle should be withdrawn and redirected slightly more medially.

Because of the loose alveolar tissue of the eyelid, a gauze sponge should be used to apply gentle pressure on the upper eyelid and supraorbital tissues before injection of solution to prevent the injectate from dissecting inferiorly into these tissues. This pressure should be maintained after the procedure to avoid periorbital hematoma and ecchymosis.

After gentle aspiration, 3 mL of solution is injected in a fanlike distribution. If blockade of the supratrochlear nerve also is desired, the needle is redirected medially and, after careful aspiration, an additional 3 mL of solution is injected in a fanlike manner. In rare cases, destruction of the supraorbital nerve by radiofrequency lesioning or supraorbital nerve stimulation may be required to provide long-lasting relief.

Underlying sleep disturbance and depression associated with the pain of supraorbital neuralgia are best treated with a tricyclic antidepressant compound, such as nortriptyline. The tricyclic antidepressant can be started at a single bedtime dose of 25 mg.

Complications and Pitfalls

Failure to diagnose supraorbital neuralgia correctly may put the patient at risk if an intracranial pathological condition or demyelinating disease, which may mimic the clinical presentation of supraorbital neuralgia, is overlooked. MRI is indicated in all patients thought to have supraorbital neuralgia. Failure to diagnose glaucoma, which also may cause intermittent ocular pain, may result in permanent loss of sight.

The forehead and scalp are highly vascular, and when performing supraorbital nerve block the clinician should carefully calculate the total milligram dosage of local anesthetic that may be given safely, especially if bilateral nerve blocks are being performed. This vascularity gives rise to an increased incidence of postblock ecchymosis and hematoma formation.

Despite the vascularity of this anatomical region, this technique can be performed safely in the presence of anticoagulation by using a 25- or 27-gauge needle, albeit at increased risk for hematoma, if the clinical situation dictates a favorable risk-to-benefit ratio. These complications can be decreased if manual pressure is applied to the area of the block immediately after injection. Application of cold packs for 20-minute periods after the block also decreases the amount of postprocedure pain and bleeding.

Clinical Pearls

Supraorbital nerve block is especially useful in the diagnosis and palliation of pain secondary to supraorbital neuralgia. The first step in the management of this unusual cause of headache is the correct fitting of swimming goggles that do not compress the supraorbital nerves. Coexistent frontal sinusitis should be ruled out in patients who do not respond rapidly to a change in swim goggles and a series of the previously mentioned nerve blocks. Any patient with headaches severe enough to require neural blockade as part of the treatment plan should undergo MRI of the head to rule out unsuspected intracranial pathological conditions.


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