Supraorbital Neuralgia

Randolph W. Evans, MD; Juan A. Pareja, MD, PhD

Key words: supraorbital neuralgia, posttraumatic headache, neuropathic pain

(Headache 2009;49:278-281)

Supraorbital neuralgia is defined by the Interna- He reported a constant aching and throbbing tional Classification of Headache Disorders-2 by the pain over the right eyebrow with an intensity ranging following diagnostic criteria: paroxysmal or constant from 3-8/10 with an average of 5-6/10 with throbbing pain in the region of the supraorbital notch and at times over the right forehead. The patient also medial aspect of the forehead in the area supplied by experienced occasional nausea, difficulty with vision the supraorbital nerve; tenderness over the nerve in focus, and some short-term memory problems but no the supraorbital notch; and pain is abolished by local dizziness, hearing loss, tinnitus, or loss of smell or anesthetic blockade or ablation of the supraorbital taste. nerve.1 There was a 15-year history of chronic migraine without aura, which had much improved when started on venlafaxine and nadolol for prevention with only 2 CLINICAL HISTORY in the prior 3 months. There was no prior history of A 45-year-old male presented following a work- significant head injury.He had not been able to return place accident 3 months prior. He had been struck by to work. a 2-pound metal hook across the right forehead with On examination, there was a scar over the right loss of consciousness for about 30 seconds. A small eyebrow and a positive Tinel’s sign over the right laceration of the right eyebrow had been sutured supraorbital nerve at the supraorbital notch. Neuro- in the emergency room. Following the occurrence logical examination was normal except for decreased of posttraumatic headaches, the patient then saw a sensation in the distribution of the right supraorbital primary care physician who prescribed naproxen nerve. sodium, and then a butalbital, acetaminophen, The patient was placed on pregabalin 75 mg twice caffeine, and codeine combination tablet without daily for 1 week and then 150 mg twice daily. When benefit. A CT scan of the brain and orbits was seen for follow-up 3 weeks later, the headache was normal. only intermittent and was brought on by movement of the head or focusing of the eyes with an intensity of 5-7/10 lasting for perhaps 2 hours. He reported no side Cases submitted by: Randolph W. Evans, MD, 1200 Binz #1370, effects of pregabalin. His memory had returned to Houston, TX 77004, USA. normal. Examination revealed the same positive Expert opinion by: Juan A. Pareja, MD, PhD, Faculty of Health Tinel’s sign and decreased sensation in the right Sciences, Rey Juan Carlos University, Neurological Depart- ment, Fundación Hospital Alcorcón, Budapest 1, 28922 supraorbital nerve distribution. The dose of pregaba- Alcorcón (Madrid), Spain. lin was increased to 300 mg twice daily.

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Questions.—What are the causes and symptoms acute trauma with direct injury resulting in neura- of supraorbital neuralgia? What medications are praxia and neurotmesis would produce early onset of effective? Are nerve blocks effective? What is the symptoms, whereas subtle/persistent trauma, fibrosis prognosis? and neuroma formation would result in a delayed onset of symptoms with rather chronic course. EXPERT OPINION Anyway, recovery would depend on the degree of There is little doubt the patient is suffering from nerve damage. supraorbital neuralgia.The combination of pain in the Application of external, brief, pressure in the territory supplied by the supraorbital nerve, Tinel’s head, such as those produced by a band around the sign at the supraorbital notch, and hypoesthesia in the head, a tight hat, oxygen and anesthetic masks, or forehead, are all features pointing to a neuropathic swimming goggles, may give rise to a headache that pain stemming from the supraorbital nerve.1,2 More- resolves once the external pressure has been over, according to the reported traumatic event the removed.11 The headache may result from a contin- nerve was presumably injured at its emergence in the ued stimulation of cutaneous nerves of the head in forehead. patients with a premorbid suceptibility to nerve com- The forehead is innervated by the supratrochlear pression. It is an in crescendo, non-pulsating head- and supraorbital nerves, both stemming from the ache without accompaniments, with maximum pain in frontal nerve, one of the terminal branches of the first the points of more external compression. Involved division of the trigeminal nerve. The frontal nerve nerves in such a type of headache seem to be mostly runs forward in the superior wall of the orbit and the supraorbital and supratrochlear ones. divides into supratrochlear and supraorbital nerves Some “primary” supraorbital neuralgia may be that exit the superior edge of the orbit, frequently due to subtle microtrauma.Progressive slow lesion can passing through an incisure or foramen (notch), and be produced at sites where the nerve is confined to supply the medial and lateral aspects of the forehead narrow anatomical passageways such as the supra- respectively. orbital notch and inside the orbit where the nerve may What are the Causes and Symptoms of Supra- be indirectly influenced by eyeball movements. In the orbital Neuralgia?—In 2 hospital-based studies of supraorbital notch a chronic compression by bony supraorbital neuralgia the disorder was generally pri- excrescencies or tissue bands may occur.2 Moreover, mary.2,3 In a large epidemiological study, however,4 the supraorbital artery accompanies the supraorbital most patients had a preceding forehead trauma. nerve passing through the supraorbital notch, where Symptomatic supraorbital neuralgia cases are usually even the nerve and the vessel may be interwoven, so, posttraumatic,4,5 and less frequently secondary to an impingement of the nerve by vascular engorgement tumors6,7 and infections.8 could theoretically occur.2,3 In the forehead, the nerve runs superficially and In the orbit, the supraorbital nerve – before may be easily damaged by a major external force exiting the orbital edge, shows an intimate relation against a hard surface (frontal bone)4,5 or during sur- with nearby vessels, oblique superior muscle, lacrimal gery.9 With major trauma antecedents, the patients gland, and the eyeball itself. We have postulated that have good recall of the event and report that the alongside such intraorbital traject the supraorbital symptoms usually started soon after the injury, nerve may be prone to intermittent subtle trauma, whereas minor trauma could be either unnoticed or during ocular movements, that would produce either underreported. When the patient can hardly relate stretching, angulation, traction, or friction of the the actual symptoms to a possible past trauma, finding nerve trunk. Since the nerve and a small artery can be a scar and a sensibility loss in the forehead retrospec- very close, an adjacent artery might produce a tively suggest a traumatic etiology.10 Otherwise, the microvascular compression of the nerve. Also, move- differences in the delay of posttraumatic symptoms ments of the superior oblique muscle might pull the may also indicate different types of nerve injury: nerve itself, either directly or indirectly through adja- 280 February 2009 cent stuck tissues. Otherwise, the nerve may also be ing, cryodenervation, even surgical ablation of the involved in structural or inflammatory processes of nerve may be necessary to abolish refractory, the orbit. unbearable, pain. Peripheral nerve stimulation of the Supraorbital neuralgia is a rare disorder of adult- supraorbital nerve has recently been reported with hood. Primary cases are slightly predominant in the promising results.13 female,2,3 whereas the posttraumatic variety seems to Are Nerve Blocks Effective?—Anesthetic block- prevail in the male.4 The age at onset is around 30-40 ade of the supraorbital nerve provides temporary years.2-6 Clinically it is characterized by a triad: (1) relief. It is more a diagnostic tool than a therapeutic forehead pain in the territory supplied by the supra- resource. Admittedly, repeated anesthetic blocks or a orbital nerve without side shift; (2) tenderness on single shot with a mixture of local anesthetic and either the supraorbital nocht or traject of the nerve; long-acting steroid may provide a rather sustained (3) absolute – but transitory – relief of symptoms relief with obvious therapeutic implications. upon supraorbital nerve blockade.2 Such 3 cardinal What is the Prognosis?—Posttraumatic supra- features have been selected as diagnostic criteria by orbital neuralgia seems to have a rather good prog- the IHS.1 The pain may be severe – typically continu- nosis since in most reported cases the symptoms ous, with paroxysmal exacerbations, and usually disappeared within one6 – some5 years, although in lacking autonomic accompaniments. Interestingly, the several ones hypoesthesia persisted. Primary cases pain may be precipitated or exacerbated by frowning. tend to display a prolonged, chronic evolution. In addition, there may be signs and symptoms of Follow-up.—When the headache was no better 3 sensory dysfunction (hypoesthesia, paresthesia, and weeks later, he received a right supraorbital nerve allodynia), and typical “neuralgic features” (lightning block with 1 cc of 1% lidocaine with great relief for pain and local, exteroceptive precipitating mecha- about 2 weeks but then recurrence.Three weeks later, nisms). However, both sensitive and neuralgic fea- he received a second block with 0.5 cc of lidocaine tures are not constantly present and seem to be more and 0.5 mg of triamcinolone with improvement for 1 frequent in the secondary – usually posttraumatic – week. He then received 3 more blocks with 1 cc of 1% forms.5 Another important issue is that posttraumatic lidocaine alone spaced 3-4 weeks apart. Seven months supraorbital neuralgia may be part of the posttrau- after the last injection (about 15 months after the matic syndrome, which includes symptoms such as injury), the pain was still fairly constant but much less concentration difficulties, memory problems, emo- with a level of 2-3/10 and about once a week 6/10 tional lability, irritability, insomnia, fatigue, disequili- on pregabalin 300 mg at bedtime (the patient had bration, dizziness, etc, presenting in various decreased the dose from twice a day to once a day on combinations. his own). The pain intensified while bending over or What Medications Are Effective?—Phar- looking up. On examination, there was still numbness macological treatment is based on antineuralgic in the right supraorbital nerve distribution. drugs. In particular, gabapentin (800-2400 mg daily) or pregabalin (150-300 mg daily) and amitriptyline REFERENCES (25-75 mg daily) proved to be of avail in some patients.2-5 Capsaicin topically applied on the 1. The International Classification of Headache Disor- ders, 2nd edition. Headache Classification Commit- symptomatic forehead has also rendered sub- tee of the International Headache Society. stantial benefits in some patients.12 Therapy may Cephalalgia. 2004;24(Suppl. 1):9-160. include surgical exploration of the supraorbital 2. Sjaastad O, Stolt-Nielsen A, Pareja JA, Vincent M. notch and eventual liberation of the nerve from Supraorbital neuralgia. The clinical manifestations tissue bands or bone excrescencies. This procedure and a possible therapeutic approach. Headache. has been remarkably successful in the group of 1999;39:204-212. patients reported by Sjaastad et al.2 Invasive proce- 3. Caminero AB, Pareja JA. Supraorbital neuralgia. A dures such as nerve rhizolisis, radiofrequency lesion- clinical study. Cephalalgia. 2001;21:216-223. Headache 281

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