Indications and Clinical Considerations
Supraorbital nerve block is useful in the diagnosis and treatment of swimmer’s headache and supraorbital neuralgia. Supraorbital neuralgia and swimmer’s headache is often the result of compression of the supraorbital nerves by swimming goggles, welding masks, respirators, etc., that fit poorly or are worn too tightly, exerting pressure on the supraorbital nerves as they exit the supraorbital foramen ( Figure 2-1 ). Repetitive microtrauma from wearing swim goggles may also cause these painful conditions. The pain of supraorbital neuralgia and swimmer’s headache is characterized as persistent pain in the supraorbital region and forehead with occasional, sudden shocklike paresthesias in the distribution of the supraorbital nerves. Occasionally, a patient with supraorbital neuralgia or swimmer’s headache will complain that the hair on the front of the head “hurts.” Sinus headache involving the frontal sinuses, which is much more common than swimmer’s headache, occasionally mimics the pain of swimmer’s headache.
Clinically Relevant Anatomy
The supraorbital nerve arises from fibers of the frontal nerve, which is the largest branch of the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital fissure and passes anteriorly beneath the periosteum of the roof of the orbit. The frontal nerve gives off a larger lateral branch, the supraorbital nerve, and a smaller medial branch, the supratrochlear nerve, and both exit the orbit anteriorly. After exiting the supraorbital foramen, the supraorbital nerve sends fibers all the way to the vertex of the scalp and provides sensory innervation to the forehead, upper eyelid, and anterior scalp ( Figure 2-2 ).
Technique
Landmark Technique
The patient is placed in a supine position. A total of 3 mL of local anesthetic is drawn up in a 10-mL sterile syringe. When supraorbital neuralgia or swimmer’s headache is treated with a supraorbital nerve block, a total of 80 mg of depot corticosteroid is added to the local anesthetic with the first block, and 40 mg of depot corticosteroid is added with subsequent blocks.
The supraorbital notch on the affected side is then identified by palpation. The skin overlying the notch is prepared with antiseptic solution, with care taken to avoid spillage into the eye. A 25-gauge, 1½-inch needle is inserted at the level of the supraorbital notch and is advanced medially approximately 15 degrees off the perpendicular to avoid entering the foramen. The needle is advanced until it approaches the periosteum of the underlying bone ( Figure 2-3 ). A paresthesia may be elicited, and the patient should be warned of such. The needle should not enter the supraorbital foramen; should this occur, the needle should be withdrawn and redirected slightly more medially.
