In order to appropriately diagnose the cranial neuralgias , it is imperative that the physician is aware of the area of the skin that is supplied by a specific cranial nerve . It is especially evident in the case of neuralgias affecting the ear which can overlap with the same areas as trigeminal neuralgia , and the nerve supplies of the inner ear and periorbital ( around the orbit of the eye ) neuralgias . The cranial neuralgias resulting in periorbital pain include supraorbital ( above the orbit of the eye ) and supratrochlear ( above the eye muscle ) neuralgia , infraorbital ( below the orbit ), and lacrimal ( relating to tear production ) neuralgia . These neuralgias are distinct from TN , but represent branches of the trigeminal nerve .
V2
V3
V1
C2
Nerves and sensory territory of peripheral cranial nerves . Legend : V1 , V2 , V3 : first , second , third trigeminal branches respectively C2 : branches of second cervical ( neck ) root .
The first branch of the trigeminal nerve consists of the supraorbital nerve , which passes through the bone notch of the upper edge of the orbit . The nerve supplies to the forehead and scalp , back to the lambdoid suture ( line of union between the parietal and occipital bones ) can be manually examined . Due to the superficiality of these nerves , most cases of supraorbital neuralgia are secondary to trauma or conditions such as wearing a tight hat or sunglasses . The disorder has a predominance in females , and is not associated with involuntary features ( tearing , eye redness , nasal congestion ) that distinguishes it from the trigeminal autonomic cephalagias . While the pain is generally thought to
be benign , associated pain has reportedly contributed to suicidal thoughts among some individuals .
The second branch of the trigeminal nerve consists of the infraorbital nerve , which exits the maxillary bone ( upper jaw ) through the infraorbital foramen ( small opening ) and supplies nerves to the side of the nose , the upper jaw , and skin of the upper lip . Cases of pure infraorbital neuralgia are rare and tend to be secondary to trauma . Diagnosis is based on location of the symptoms and response to blockade with a numbing medication .
Lacrimal neuralgia from the medial branch of the lacrimal nerve supplies nerves to the anterior temple and lateral eyelid . Tenderness and continued pain at the outer top edge of the orbit can be observed .
The third branch of the trigeminal nerve consists of the auriculotemporal ( ATN ). The ATN passes beneath the mandibular ( lower jaw ) condyle ( articulated part of the bone ) going toward the temporal region and can be felt in the pre-auricular region in front of the tragus ( projection in the ear ) and supplies the skin covering the front of the helix ( incurved rim of the outer ear ) and tragus and skin of the temporal region . Similar to other neuralgias , the pain is piercing and sudden . It may be accompanied by facial sweating and flushing termed “ Frey ’ s Syndrome ,” following the removal of the parotid gland ( beside the ear ) or trauma to the area . ATN responds well to botulinum toxin type A .
Nerve blockade or blocking or temporarily deadening the nerve is an effective technique that has been successful in the treatment of facial and auricular neuralgias . This technique often uses a combination of a numbing medication , such as lidocaine or bupivacaine , and may be combined with a steroid . A needle is inserted near the particular nerve and the medication is injected . Nerve blockade is often done in the office and is minimally painful . Depending on the case , this technique can provide immediate pain relief that can last weeks to months . However , in some instances it may provide permanent pain relief .
A recent article in Cephalagia authored by Gaul and Resch , discussed the application of capsaicin 8 % in a cutaneous ( skin ) patch to the head and face to treat nonresponsive nerve pain . Capsaicin , the primary pungent ingredient in hot chili peppers , works with a key receptor in
16 HeadWise ® | Volume 6 , Issue 1 • 2016