Supraorbital neuralgia is characterized by persistent pain in the supraorbital region and forehead with occasional sudden, shock-like paresthesias in the distribution of the supraorbital nerve. 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 swimming goggles that are too tight. This clinical syndrome also is known as swimmer’s headache.
The headache might not present for many years until the scar cicatrix tightens enough around the nerve to finally cause entrapment.
Supraorbital neuralgia is characterized by paroxysmal or constant pain in the region of the supraorbital notch and medial aspect of the forehead in the area supplied by the supraorbital nerve. 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.
The supraorbital is purely a general sensory (afferent) nerve. The supraorbital nerve is a continuation of the frontal nerve, which is one of the three main branches of the ophthalmic division (V1) of the trigeminal nerve.
The supraorbital nerve exits from the supraorbital foramen or notch along the superior rim of the frontal bone, accompanied by the supraorbital artery. In the supraorbital notch, the supraorbital nerve gives off small filaments that supply the mucosal membrane of the frontal sinus and filaments that supply the upper eyelid.
Supraorbital neuralgia is characterized by the following triad:
There can be lacrimation, scleral injection, and sudden stabbing pain that can mimic cluster headaches. Nausea may also be present.
Pain syndromes that may mimic supraorbital neuralgia include migraine headaches, 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.
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 swimming goggles). Non-pharmacological treatments like TENS and acupuncture can be tried.
Anti neuropathic drugs like tricyclic antidepressants and antiepileptics (gabapentin, pregabalin) can help relieve the symptoms.
Infiltration of local anaesthetic and steroid around the supraorbital nerve can be diagnostic and therapeutic as well. The injection is performed under real-time ultrasound guidance for greater accuracy and safety.
Pulsed radiofrequency lesioning of the supraorbital nerve is indicated in patients who show a positive response to diagnostic supraorbital nerve blocks. This procedure can relieve symptoms associated with supraorbital neuralgia on a long-term basis.
Injection of botulinum toxin can be helpful in relieving symptoms associated with supraorbital neuralgia.