Nasal Neuralgias – What to Do

A Nose pain issue with pain out of control could represent a nasal neuralgia with  a treatable injection regimen.

External Nasal Neuralgia

García‐Moreno, Héctor, et al.
External nasal neuralgia: A neuropathic pain within the territory of the external nasal nerve.
Headache: The Journal of Head and Face Pain 55.9 (2015): 1259-1262.


  • potential causes trauma, infection, cancers and unknown “idiopathic rhinalgia”
  • idiopathic forms have various names – nasociliary neuralgia (Charlin’s neuralgia)
    infratrochlear neuralgia
  • case 76 yr old lady with 30 year history initially of paroxysms of mild tingling sensation on side of nose – mostly during day
  • amitriptyline helps
  • changed to severe pains lasting 20-30 minutes occurring  2-3 times a day
  • nose was tender and palpation could trigger attack
  • tenderest spot was where bone ended and cartilage started
  • blood work oncluded EST and CT face was normal

Treatment involves injection:

  • injections of 0.5 mL of bupivacaine 0.5% with a 30-gauge needle every few months gave relief
  • spot where bone ends is the best spot
  • used 4% intranasal lidocaine as well



Another naso-facial neuralgias written up:

Infratrochlear Neuralgia:

Pareja, Juan A., et al.
Infratrochlear neuralgia.
Cephalalgia 35.13 (2015): 1202-1207.

The Infratrochlear nerve:

  • comes from nasociliary nerve (one of the terminal
    branches of V-1)
  • follows the inferior edge of the superior oblique muscle up to its
  • leaves orbit below the trochlea
  • feeds the medial aspect of the upper eyelid
  • also feeds the  bridge of the nose
  • also feeds the  lacrimal sac and caruncle.

  • They excluded eyeglass trauma which one would think is relevant to that location

Tests they thought relevant were:

  • ESR, CRP
  • “Immunological tests, including quantitative immunoglobulin testing”
  • RA factor
  • Lupus anticoagulant
  • ANA for lupus
  •  anticardiolipin antibodies
  •  antithyroid antibodies;
  • MRI brain and paranasal sinuses


  • Mostly women – 6 female; 1 man
  •  age average – 46 (13-73)
  • problems 1 month 1 2 years
  • spontaneous onset
  • paroxysmal, shot-like pain
  • severe 7+/10

Location fixed to one of 3 locations:

  • internal angle of the orbit and upper
    eyelid (3)
  • side of the bridge of the nose (3)
  • lacrimal caruncle (1)


  • Pain lasted 5-30 seconds
  • daily 1-20 attacks a day
  • 2/6 could trigger it with touch
  • though random, did not occur at night
  • local excessive tenderness


  • Gabapentin ( most on 900 mg/day) worked well in all cases and was able to be stopped in 2-6 months
  • one underwent remission with injection –  “injecting 0.5 cc of bupivacaine 0.5% with a 30-gauge needle through the internal angle of the orbit, just below the trochlear area”

Comment – you see what you know – and injection or  gabapentin seems to be the ticket

Post‐Traumatic External Nasal Pain Syndrome

In real life, post-traumatic nasal pain cases are much more complicated:

Rozen, Todd.
Post‐Traumatic External Nasal Pain Syndrome (a Trigeminal Based Pain Disorder).
Headache: The Journal of Head and Face Pain 49.8 (2009): 1223-1228.

Article presents 4 cases with variety of nerve involvements

1 – pregabalin 675 mg worked well

2 – snorkeling injuries –

  • daily pain “on both sides and the bridge of his nose” – became extremely disabled
  •   bilateral supratrochlear, infraorbital and bilateral maxillary nerve blocks only gave short term results.
  • Left sphenopalatine ganglion block gave good relief so had left sphenopalatine ganglion rhizolysis, which made his pain >75% improved.
  • Surgical  treatment of deviated septum with contact point helped gain good control

3 –  lady with pain and sensitivity whole nose  after an assault. –

  • local blocks were short term and botulinum minimally effective.

Point here – I find botulinum injections in neuropathic pain softens up the nerve to blocks especially treatment with semineurolytic agents like 5-10% lidocaine.  So just expecting botulinum to work is too much to expect but a combo use gets good results.

  • As it was,  she then had excellent response to several nerve blocks.
  • Not realizing why the results of the combo worked well, they went on a different tack to sphenopalatine rhizotomy which worked for 1 year.
  • Following that,  had right maxillary nerve pulsed radiofrequency with some relief.
  • Then had bilateral infratrochlear blocks and then pulsed radiofrequency of the infratrochlear nerves with good results.

Goes to show that perseverance pays off

4 – 14 yr old with bridge nose and bilateral lateral portions

  • worse with valsalva and exercise. May have had trauma from repeatedly “heading” ball playing soccor
  • got bad enough for hospitalizations twice
  • had a persistent component and a severe overlying part
  • regimens for migraine include IV were ineffective
  • supraorbital and supratrochlear blocks failed; infratrochlear blocks short lived with rebound pains
  • botulinum failed
  • trigger injections failed
  • nasal contact surgery failed
  • memantine 30 mg gave good relief for past 2 years and flares were handled by “short dexamethasone taper”
  • sphenopatine block was considered but costs prevented it

wow – hurray for memantine

Comment – What I got from these articles is:

  • Know your nerves and where to block but if you are serious about a nerve you need to consider rhizotomy
  • Botulinum PLUS subsequent nerve blocks might help but  botulinum alone is rarely effective
  • Nasal contact surgery might help if septum deviated enough to contact side of nose – helped 1/2 of time (in 2 cases so far)
  • Sphenopalatine block worth using  and if successful, subsequent rhizotomy is an alternative
  • Pregabalin higher dose, and memantine  might be worth a try



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