Nerve block in supraorbital neuralgia, efficient for each prognosis and therapy

Approximately 8% of the subjects in a recent study of 1,126 patients with thyroid disease developed symptoms of supraorbital neuralgia and often described the pain as burning, throbbing, or something like a nail “driven through the head”. Supraorbital neuralgia (SON) pain is sometimes misdiagnosed, not adequately reported, and management options are not yet widely available, according to researchers who completed the analysis.

Of the total participants, 946 (84%) reported pressure or pain behind or around at least 1 eye. In 91 subjects, the more pronounced SON-type symptoms were debilitating – they reported pain radiating laterally across the supraorbital margin, moving up the forehead, or lingering behind the eye. All participants with suspected SON received a supraorbital nerve block, and 3 also received zygomatic temporal, zygomatic-facial, or supratrochlear nerve blocks. Remarkably, 100% felt relief from symptoms within 15 minutes, and that relief from symptoms continued after 24 hours, according to investigators.

In addition to anesthetic nerve block, two effective treatment options included either orbital decompression surgery or a neuroleptic combination of gabapentin, Dilantin, and Tegretol. Corticosteroids reduced pain marginally, and nonsteroidal and vasoactive migraine drugs were the least helpful, the researchers added.

The researchers suspect that the onset of SON is caused by a combination of hydrostatic-compressive pressure on the frontal nerve and an intrinsic neurogenic process. Study participants whose thyroid eye disease was reactivated were more likely to have had SON than subjects in a primary activation stage. “So one might wonder if there is a mechanistic link between the development of SON and reactivation,” they added.

SON can also indicate a higher risk for orbital decompression surgery. Overall, this operation was indicated by proptosis and exposure keratopathy (57%), optic neuropathy (34%), pain (7%), glaucoma progression (2%), and aesthetics (0.04%). “Patients with SON-type pain were almost twice as likely to experience orbital decompression as 88 out of 91 (97%) over the 7 years of the study compared to patients without 496 out of 1,035 (48%),” the researchers said. “Even if the 30 patients whose primary indication for decompression was pain are excluded, the decompression rate in those with SON was 64% and is still different from those without.”

The research period included a 4-year retrospective analysis of patients in a major referral practice for tertiary thyroid eye disease in the United States. The investigators used 3 standard scoring systems; European Group of Graves (EUGOGO) vision, inflammation, strabismus and appearance (VISA), clinical activity value (CAS) and orbitopathy. The researchers found no association between SON-type pain and the amount of exophthalmos, gender, age, smoking status, duration of illness in the active phase, or size of extraocular muscles on CT. Those with SON pain did not differ significantly in their mean CAS, VISA or EUGOGO values ​​from the total study population.

Limitations included a possible underestimation or overestimation of the SON for thyroid disease due to the strict inclusion criteria or the disease stage of the referring study population. The placebo effect was also not taken into account. In addition, patients with optic neuropathy in the tertiary clinic were offered orbital decompression surgery at an early stage, which alone excludes an improvement in the SON.


Patrisch J, Hamilton K, Parke R, Patrisch R, Soparkar C. Supraorbital neuralgia associated with a thyroid eye disease. Plastic and reconstructive eye surgery. Published online June 17, 2020. doi: 10.1097 / IOP.0000000000001762.

This article originally appeared on Ophthalmology Advisor

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