Supraorbital neuralgia is another possible cause of severe headaches.
It is due to damage to the supraorbital nerve just above (supra = above), the eye ( orbit = the eye socket).
People who report this pain may have a history of a blow to the head, or even a previous black eye.
The original reports from the 1980's included 2 neurologists who developed the pain after swimming with ill-fitting goggles - the term "goggle headache" was applied for a while.
The jabs and jolts ( which sound a bit like ice-pick headaches) occur strictly in the sensory area of the supra-orbital nerve. The neuralgia is locked to the affected side.
This is unlike ice-pick pains which can switch between different sites or sides of the scalp.
When testing that area of scalp with a pin, the skin may have reduced sensation or be abnormally sensitive to pin-prick testing.
The pain does not have the sensory sensitivity of migraine (nausea, and intolerance to light, noise, or movement), nor the autonomic activation of cluster headache (eye watering, nasal stuffiness, reddening of the eye, drooping of the eyelid).
The examination should always include pressing around the margins of the eye-socket, and usually over the inner third of the upper rim of the eye-socket the tender supraorbital nerve is found.
The syndrome is quite rare. In the famous Vaga Headache Epidemiology Study, only 10 out of 1838 people surveyed had this type of pain (0.5%). Of these 10, 50% reported a previous injury.
Supraorbital neuralgia treatment
Historically, people with this type of cranial neuralgia had a provoking factor such as ill-fitting goggles (swimmers).
I have seen a man with a motorcycle helmet as a cause of this type of pain.
If these are the cause, the treatment is to remove the provoking stimulus - better fitting helmet or goggles.
I have never seen a case of a swimmer with supraorbital neuralgia in over 15 years practice. Change in goggle design must take some credit!
If a local anaesthetic injection relieves the pain, a nerve block with methylprednisolone could provide longer term relief.
Low dose anti-convulsants such as Gabapentin or Pregabalin are also useful. One person I know used to take a very severe headache in the front of the head during which they would fall down to the ground - a drop attack.
These reduced in frequency following nerve block and continued long term anti-convulsant treatment.
A very recent paper demonstrated that a nerve stimulator device could be successfully applied to the supra-orbital nerve to relieve supraorbital neuralgia (Amin 2008). The patients treated with nerve stimulation reduced their use of powerful, opioid (morphine-like) painkillers.
In severe cases, decompression of the supraorbital nerve has been attempted (by the same people from Vaga).
Surgery is not, by any means, proven.
Some people's supraorbital nerve sits in a groove (the supraorbital notch), whereas other run through a small hole (the supraorbital foramen) which offers more protection at the brow of the forehead.
It is said that those with a notch are more at risk of neuralgia.
Supraorbital neuralgia treatment
- Better fitting goggles / helmet - prevention is better than cure
- Nerve Block with lidocaine and methylprednisolone
Supraorbital Nerve Stimulator Device Minor Decompressive Surgery to the Supraorbital Nerve
- Gabapentin Pregabalin
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