Treatment Options for Cranial Neuralgias

A review of treatment and coding options for various cranial neuralgias.

By Martin T. Taylor, DO, PhD
 

Cranial neuralgias may present to the neurology clinic as a localized head or facial pain or coexist with other headache syndromes, such as migraine. They can be an important factor in patients with chronic refractory headaches. Nerve irritation/damage can present in multiple anatomic areas including the occipital nerves, trigeminal nerves, and sphenopalatine ganglion. Direct trauma, vascular compression, fibrous entrapment, infection, and iatrogenic from cranial surgery are common causes of neuralgias.

Treatment Options

Neurologists have numerous conservative treatment options for cranial neuralgias. Non-pharmacologic treatments such as physical therapy, traction, or manual therapy may be particularly helpful for some neuralgias such as occipital neuralgia.1,2 Topical treatment with ice, anesthetic creams, or capsaicin cream may be used adjunctively especially in facial pain.3,4 Treatment with medications tends to be the mainstay for neurologists, especially for those that do not perform injections. Oral steroids can be used effectively as an initial treatment in attempt to break the pain cycle.5 Neuromodulating agents (trycylic antidepressants, serotonin-noradrenaline reuptake inhibitors, anti-epileptic, and lioresal) can give patients long-term relief and potentially result in temporary remission of symptoms.6 Evidence also suggests that botulinum toxin injections may be helpful in neuralgias.7,8 The majority of supportive data on pharmacologic treatments is seen for trigeminal neuralgia. According to the Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies, level A evidence supports the use of carbamazepine, while oroxcarbazepine’s evidence is level B and lioresal/lamotrigine demonstrate level C.9 Other medications suggesting efficacy include topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin A.10 

Tramadol and tapentadol may be considered the best narcotic option for breakthrough or refractory pain, given their dual anti-nociceptive and anti-neuropathic effects.11

OCCIPITAL NEURALGIA DIAGNOSTIC CRITERIA

  • Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves
  • Tenderness over the affected nerve
  • Pain is eased temporarily by local anesthetic block of the nerve

Neurologists are well equipped to perform minimally invasive extra-cranial nerve blocks with anesthetic and steroids in clinically appropriate patients. This in-office procedure has been demonstrated to reduce the frequency, intensity, and duration of cranial pain for not only neuralgias but also secondarily in migraines, cervicogenic headaches, hemicranias continua and cluster headaches.12,13,14 Nerve blocks can be used as an abortive or prophylaxis treatment.

However, neurologists may consider referrals to a surgeon or interventionalist for more invasive treatments, such as radiofrequency ablation, decompression, rhizotomy, or neurostimulation in the refractory clinically appropriate or refractory patient.15,16

Occipital Nerve Blocks

According to the International Headache Society Classification, occipital neuralgia is defined as “Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves.”17 Tenderness to palpation over the affected nerve with temporary pain relief after an anesthetic block are also required to meet criteria. In addition, the pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements.

ICD-10 / CPT Codes Options For Extracranial Neuralgias

Occipital nerve blocks

ICD-10 Codes

M54.81 Occipital neuralgia

M79.1 Neuralgia and neuritis, unspecified M50.11 Cervical disc disorder with
radiculopathy, high cervical region


CPT Codes

64405 Injection, anesthetic agent;
greater occipital nerve

64450 Injection, anesthetic agent;
other peripheral nerve or branch


Trigeminal neuralgia

ICD-10 Codes

G50.0 Trigeminal neuralgia

G50.1 Atypical pain


CPT Code

64400 Injection, anesthetic agent; trigeminal nerve, any division or branch


Sphenopalatine ganglion blocks

ICD-10 Codes

G50.0 Trigeminal neuralgia

G50.1 Atypical pain

G43.911 Migraine, unspecified, intractable,
with status migrainosus

G43.819 Other migraine, intractable, without status migrainosus


CPT Code

64505 Injection, anesthetic agent;
sphenopalatine ganglion

The therapeutic use of occipital nerve blocks can be very helpful as the main treatment of occipital neuralgia or as an adjunct to medications and non-pharmacologic treatments. A single injection may provide pain relief for up to several weeks or even resolution.18,19 The predominance of the literature analyzes treatment of the greater occipital nerve which may be why many clinicians block this nerve alone. The clinician needs to pay particular attention to the distribution of pain as one or more nerves may be involved. All three occipital nerves originate from C2-C3 but the cranial pain distribution of each nerve is quite distinct. The lesser nerve distribution extends laterally over the ear, the greater extends more medial and towards the crown of the head, and the third nerve supplies a central and more inferior portion of the scalp.20

Medication Treatment for Trigeminal Neuralgia


Level of Evidence Medication


A Carbamazepine


B Oxcarbazepine


C lioresal, lamotrigine topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin-A

Trigeminal Nerve Blocks

The typically paroxysmal electric shock-like pains of trigeminal neuralgia can occur in one or all of the divisions but is most common in V2 and V3.21 Herpes zoster on the other hand occurs 80 percent of the time in V1. Extracranial infraorbital and mental nerve blocks can quickly and easily be performed in the office for acute and chronic pain relief in these regions. Supraorbital, supratrochlear, and zygomaticofacial blocks may be useful after facial trauma.22 while zygomaticotemporal or auriculotemporal nerve blocks can be utilized in the patient with temple pain23 particularly associated with bruxism for temporomandibular dysfunction. The use of steroids in facial injections needs to be considered judiciously because of the possibility of fat atrophy causing an untoward cosmetic side effect.

Opthalmic (V1): Suprorbital, supratrochlear, and infratrochlear branches innervate the forehead, orbits, and nose.

Maxillary (V2): Zygomaticotemporal, zygomaticofacial, and infraorbital branches innervate the upper temple, cheek and upper lip/teeth.

Mandibular (V3): Auriculotemporal, buccal, and mental branches innervate the temple, mandible, lower teeth, and chin.

Sphenopalatine Ganglion Blocks

Sphenopalatine ganglion blocks offer another in office procedure to the neurologist for the patient with facial pain or headache. Relief has been demonstrated in sphenopalatine neuralgia, trigeminal neuralgia, atypical facial pain, and cluster headaches.24,25 Acute relief of migraine headaches has also been demonstrated.26 While interventionalists use fluoroscopic guidance to perform this injection,27 intranasal devices (Sphenocath®/ Tx360®) offer a less invasive in-office option. n

Martin T. Taylor, DO, PhD is Clinical Associate Professor at the Ohio University College of Osteopathic Medicine.

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2. Espí-López G et al. Effectiveness of Physical Therapy in Patients with Tension-typeHeadache: Literature Review. J Jpn Phys Ther Assoc. 2014;17(1):31-8.

3. Derry S et al. Topical lidocaine for neuropathic pain in adults. Cochrane Database Syst Rev. 2014 Jul 24;7

4. Provinciali L et al. Topical pharmacologic approach with 5% lidocaine medicated plaster in the treatment of localized neuropathic pain. Minerva Med. 2014 Dec;105(6):515-27.

5. Han SR et al. Early dexamethasone relieves trigeminal neuropathic pain. J Dent Res. 2010 Sep;89(9):915-20.

6. Finnerup NB et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73.

7. Londe M et al. Botulinum toxin treatment of secondary headaches and cranial neuralgias: a review of evidence. Acta Neurol Scand Suppl. 2011;(191):50-5.

8. Mittal SO et al. Botulinum Toxin Treatment of Neuropathic Pain. Semin Neurol. 2016 Feb;36(1):73-83.

9. Gronseth G et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct 7;71(15):1183-90.

10. Al-Quliti KW. Update on neuropathic pain treatment for trigeminal neuralgia. The pharmacological and surgical options. Neurosciences (Riyadh). 2015 Apr;20(2):107-14.

11. Tzschentke TMChristoph TSchröder WEnglberger WDe Vry JJahnel UKögel BY. Tapentadol: with two mechanisms of action in one moleculeeffective against nociceptive and neuropathic pain. Preclinical overview. Schmerz. 2011 Feb;25(1):19-25.

12. Blumenfeld A et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013 Mar;53(3):437-46.

13. Guerrero ÁL et al. Peripheral nerve blocks: a therapeutic alternative for hemicrania continua. Cephalalgia. 2012 Apr;32(6):505-8.

14. Dach F et al. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015 Feb;55 Suppl 1:59-71.

15. Ducic I et al. A systematic review of peripheral nerve interventional treatments for chronic headaches. Ann Plast Surg. 2014 Apr;72(4):439-45.

16. Papuć E and Rejdak K. The role of neurostimulation in the treatment of neuropathic pain. Ann Agric Environ Med. 2013;Spec no. 1:14-7.

17. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808.

18. Inan LE et al. Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study. Acta Neurol Scand. 2015 Oct;132(4):270-7.

19. Saracco MG et al.Greater occipital nerve block in chronic migraine. Neurol Sci. 2010 Jun;31 Suppl 1:S179-80. doi: 10.1007/s10072-010-0320-7.

20. Loukas M et al. Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 2006 Nov;65(4):337-42.

21. Cheshire WP Jr. Cranial Neuralgias. Continuum (Minneap Minn). 2015 Aug;21(4 Headache):1072-85.

22. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010 Apr;7(2):197-203.

23. Speciali JG et al. Auriculotemporal neuralgia. Curr Pain Headache Rep. 2005 Aug;9(4):277-80.

24. Piagkou M et al. The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. Pain Pract. 2012 Jun;12(5):399-412.

25. Peterson JN et al. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Cranio. 1995 Jul;13(3):177-81.

26. Cady R et al. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine. Headache. 2015 Jan;55(1):101-16.

27. Yang lY and Oraee S. A novel approach to transnasal sphenopalatine ganglion injection. Pain Physician. 2006 Apr;9(2):131-4.

 

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