Nerve Block Management Insights for the Hemicrania Continua

Discover the latest insights on nerve block management for headaches, including hemicrania continua, for enhanced treatment approaches.

Abstract

Chronic headaches represent a significant burden on individuals’ quality of life, often presenting diagnostic and therapeutic challenges. This educational post explores the intricate neuroanatomy of craniofacial pain, focusing specifically on Hemicrania Continua, a rare but debilitating primary headache disorder. We will examine a case study of a 71-year-old woman with a right-sided headache, detailing the diagnostic process and the use of targeted peripheral nerve blocks as a therapeutic intervention. This article, written from my perspective as a clinician, aims to illuminate the physiological mechanisms behind such headaches and explain the rationale for using a combination of lidocaine and bupivacaine to interrupt pain signals. We will also discuss how this procedure fits within a broader, integrative care model. At Injury Medical Clinic, we combine advanced medical diagnostics and interventions under the direction of our Medical Director, Dr. Maria Guadalupe Cardenas, MD, with holistic, non-invasive therapies like chiropractic care, functional medicine, and rehabilitation. This collaborative approach lets us address not only immediate symptoms but also the underlying biomechanical and systemic dysfunctions that contribute to chronic pain, offering patients a comprehensive, personalized path to lasting relief.

Our Multidisciplinary Philosophy: Integrating Medicine and Chiropractic Care

At Injury Medical Clinic, our mission is to provide comprehensive, patient-centered care that addresses the full spectrum of health and wellness. We believe that the most effective path to healing lies in a collaborative, multidisciplinary approach. This philosophy is embodied in the partnership between me, Dr. Alex Jimenez, a Doctor of Chiropractic with advanced practice nursing and functional medicine certifications, and our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD.

Dr. Cardenas is a Board-Certified Internist with a distinguished career spanning over 40 years. Her extensive experience in internal medicine provides the critical medical oversight and diagnostic acumen that form the foundation of our clinical practice. As our collaborative physician, she guides our medical protocols, upholds the highest standards of patient safety, and works hand in hand with our team to develop integrated treatment plans. Her NPI number is 1164426749, and she is licensed to practice in Texas under license #J2933.

This unique synergy allows us to bridge the gap between conventional medicine and holistic therapies. While Dr. Cardenas provides the essential medical framework—including prescribing medications, ordering advanced imaging, and overseeing medical procedures like the nerve blocks discussed in this article—my role focuses on the biomechanical, neurological, and functional aspects of health. We integrate:

• Medical Diagnostics & Interventions: Led by Dr. Cardenas, this includes thorough medical evaluations, differential diagnoses, and targeted procedures to manage acute symptoms and underlying medical conditions.
• Chiropractic Care: I use precise spinal and extremity adjustments to restore proper joint mechanics, alleviate nerve compression, and improve overall nervous system function. This is crucial for headache patients, as cervical spine dysfunction often contributes.
• Functional Medicine: We investigate the root causes of chronic illness by looking at lifestyle, genetics, diet, and environmental factors. This approach helps us address systemic inflammation, hormonal imbalances, and nutritional deficiencies that can perpetuate pain cycles.
• Rehabilitation & Personal Injury Care: Our team provides targeted physical therapies and rehabilitative exercises to strengthen supporting muscles, improve posture, and restore function after an injury, which is often the genesis of chronic pain conditions.

By weaving these disciplines together, we create a patient journey that is both comprehensive and deeply personalized. A patient with chronic headaches, for example, may receive a medical diagnosis and a targeted nerve block from our medical team while also undergoing chiropractic adjustments to correct cervical spine alignment and receiving a functional medicine plan to reduce systemic inflammation. This is the power of integrative care—addressing the patient as a whole person, not just a collection of symptoms.

A Deeper Look into Hemicrania Continua: Understanding the Challenge

This morning, on September 1, 2026, I had the privilege of treating a 71-year-old woman who presented with a persistent, right-sided headache. Her condition is known as Hemicrania Continua, a type of primary headache disorder that is both rare and profoundly impactful on a person’s life. The term itself offers a clue to its nature: hemi meaning “half,” and crania meaning “head.” The defining feature is a continuous, unilateral headache that varies in intensity but never completely resolves. Autonomic symptoms often accompany it on the same side as the pain, such as eye-watering, nasal congestion, or a drooping eyelid.

Unlike more common headaches like migraines or tension-type headaches, Hemicrania Continua has a unique characteristic: it responds completely to the non-steroidal anti-inflammatory drug (NSAID) indomethacin. This response is so reliable that it is considered a cornerstone of its diagnosis. However, long-term use of indomethacin can carry significant gastrointestinal and cardiovascular risks, making it an unsuitable solution for many patients, particularly older adults. This is where alternative and integrative therapies become not just beneficial, but essential.

For this particular patient, her headache was not just a dull, constant ache. It was punctuated by moments of severe, sharp pain, and she described her baseline pain level as a distressing seven out of ten on the pain scale. My immediate goal was to provide rapid and effective relief while also gathering diagnostic information to guide her long-term treatment plan. The first step was a detailed physical examination to pinpoint the precise sources of her pain.

Identifying the Pain Triggers: A Neurological Road Map

Pain is not a monolithic experience; it is a complex signal transmitted by specific nerves. In cases of facial and head pain, the trigeminal nerve (Cranial Nerve V) and sensory branches from the cervical plexus are often the primary conduits. The trigeminal nerve is a massive nerve with three main branches that provide sensation to the face:

1. Ophthalmic Division (V1): Supplies the forehead, scalp, upper eyelids, and the front of the nose.
2. Maxillary Division (V2): Supplies the mid-face, including the lower eyelids, cheeks, upper lip, and upper teeth.
3. Mandibular Division (V3): Supplies the lower face, including the jaw, lower lip, chin, and parts of the ear and temple.

In my examination, I used gentle yet firm palpation to systematically assess the terminal branches of these nerves, looking for areas of exquisite tenderness, known as allodynia (pain from a stimulus that does not normally provoke pain) or hyperalgesia (an increased response to a painful stimulus). This process is like tracing a neurological road map to find the specific pathways broadcasting pain signals.

My examination revealed four distinct points of significant tenderness, each corresponding to a specific peripheral nerve branch:

• The Supratrochlear Nerve: This is a small terminal branch of the ophthalmic division of the trigeminal nerve. It emerges from the upper-medial aspect of the orbit (the bony socket of the eye). It provides sensation to the skin of the medial forehead, just above the eyebrow near the bridge of the nose. When I applied light pressure to this area, the patient immediately confirmed sharp pain. This nerve can become entrapped or irritated as it passes through the fascia and muscle of the forehead, particularly the corrugator supercilii muscle.
• The Supraorbital Nerve: Also a branch of the ophthalmic division, this is a larger nerve that exits the skull through a small notch or foramen in the supraorbital rim (the bone just above the eye). It supplies a much larger area of the forehead and the front of the scalp. Palpating this nerve, located roughly in the middle of her eyebrow, elicited a similar, strong pain response. Compression at the supraorbital notch is a well-documented cause of frontal headaches.
• The Zygomaticotemporal Nerve: This nerve is a branch of the maxillary division of the trigeminal nerve. It travels through a small canal in the zygomatic bone (cheekbone) and emerges in the temporal region, just lateral to the eye. It provides sensation to the skin over the “temple.” When I pressed on this location, the patient again reported significant pain. Tension in the temporalis muscle, a large, fan-shaped muscle involved in chewing, can irritate this nerve.
• The Auriculotemporal Nerve: A branch of the mandibular division, this nerve has a more complex path. It runs deep to the jaw joint (temporomandibular joint, or TMJ) and ascends in front of the ear to supply the skin of the temple and scalp. It is often implicated in headaches associated with TMJ dysfunction or tension in the surrounding muscles. Palpation of this area, just anterior to her ear, was the fourth and final trigger point.

Identifying these four specific nerves—supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal—was a critical diagnostic step. It confirmed that her headache was not diffuse, nonspecific pain but was driven by irritation of these specific peripheral nerve branches. This finding immediately opened the door for a highly targeted and effective treatment: peripheral nerve blocks.

The Therapeutic Intervention: Performing Peripheral Nerve Blocks

A peripheral nerve block interrupts pain signals at their source. It involves injecting a small amount of local anesthetic directly at the site of an irritated nerve. This “blocks” the transmission of pain signals from that nerve to the brain, providing immediate and often profound relief. For this patient, the goal was twofold: first, to provide immediate relief from her debilitating headache (a therapeutic goal), and second, to confirm that these four nerves were indeed the primary drivers of her pain (a diagnostic goal). A successful block would validate our findings and help shape the long-term management strategy.

Preparing for the Procedure

Precision and safety are paramount in any medical procedure, especially when working near sensitive structures like the eye.

1. Marking the Injection Sites: I began by carefully re-identifying the four tender points. To avoid causing unnecessary discomfort, I used the retracted tip of a ballpoint pen to make a very light ink mark at each location. Heavy pressure here could pre-emptively irritate the nerves, so a gentle touch is key.
2. Aseptic Technique: Next, I prepped the entire area with Betadine, an antiseptic solution, to sterilize the skin and minimize infection risk. Cleanliness is non-negotiable.
3. The Anesthetic Cocktail: For the injection itself, I prepared a specific mixture of two different local anesthetics:

• • 5% Lidocaine with Epinephrine: Lidocaine is a fast-acting anesthetic. Its effects begin almost immediately, typically within a minute or two. This makes it ideal for rapid pain relief. The addition of epinephrine is crucial. Epinephrine is a vasoconstrictor, meaning it narrows the blood vessels in the area. This serves two important purposes: it reduces bleeding at the injection site and, more importantly, keeps the lidocaine concentrated around the nerve longer, prolonging its effect and reducing systemic absorption.
  • Bupivacaine: Bupivacaine is a long-acting anesthetic. While it takes longer to kick in (typically 5-10 minutes), its effects can last for several hours, sometimes even longer.

• • By combining these two agents in a 50/50 mixture, we get the best of both worlds: the rapid onset of lidocaine for immediate relief and the extended duration of bupivacaine to “break” the pain cycle for a prolonged period. The hope is that this extended period of quiet for the nerve will allow it to reset, reducing its hyperexcitability even after the anesthetic wears off. I planned to inject a total of one milliliter (1 mL) of this mixture at each of the four sites.

The Injection Technique: Precision and Safety

For the injections, I used a very fine 30-gauge, half-inch needle. This needle is extremely thin, which helps minimize injection discomfort. In many procedures, we might use a topical anesthetic spray (like ethyl chloride) to numb the skin first. However, given the proximity to the patient’s eye, using a freeze spray was not a safe option. The risk of the spray entering the eye is too great. In this case, the momentary pinch of the fine needle is far less uncomfortable and much safer than the alternative.

My technique for each injection followed a precise and safety-oriented protocol:

• Protecting the Orbit: For the two nerves located along the orbital rim (supratrochlear and supraorbital), I placed my thumb firmly against the bone just below the injection site. This technique acts as a physical barrier, or a bolster. As I injected the anesthetic, the fluid created pressure under the skin. My thumb prevented this fluid from dissecting downward into the delicate tissues of the orbit and eye socket. I felt the fluid pressure building against my thumb, confirming that the anesthetic was spreading laterally across the forehead as intended, rather than migrating toward the eye.
• Locating the Nerve: I gently advanced the needle until I felt the tip make light contact with the underlying bone (the periosteum). This is a critical anatomical landmark. The nerves we are targeting lie just on top of the bone. By touching the bone and then slightly withdrawing the needle (about 1-2 millimeters), I could be confident that the tip was positioned precisely in the fascial plane where the nerve resides.
• Aspiration: Before injecting any of the anesthetic, I performed a crucial safety check: aspiration. This involves gently pulling back the syringe plunger to create negative pressure. If the needle tip were inside a blood vessel, blood would be drawn into the syringe. This is a “positive aspiration.” Seeing blood would mean I need to reposition the needle before injecting. Injecting anesthetic directly into an artery or vein can lead to serious systemic side effects, such as cardiovascular changes or central nervous system toxicity. For injections in the temporal region (zygomaticotemporal and auriculotemporal), this step is particularly vital because of the proximity of the superficial temporal artery. In all four of my injections, aspiration was negative, meaning no blood was withdrawn, and I could proceed safely.
• Injection: With the needle correctly positioned and aspiration confirmed negative, I slowly and steadily injected the 1 mL of anesthetic mixture at each of the four sites. The patient was incredibly brave and tolerated the procedure exceptionally well, reporting only a slight “pinch” on a couple of the injections.

Assessing the Outcome: Immediate and Measurable Relief

The true test of the procedure, of course, is the patient’s response. Lidocaine works quickly, so we can often assess the initial success of the blocks within minutes.

Before we began, the patient had rated her headache pain as a 7 out of 10. This was her baseline at that moment. Immediately after completing the four injections, I asked her to re-evaluate her pain.

“What number would you assign your headache right now?” I asked.

She paused, assessing her symptoms. “I think it’s better,” she replied. “More like a five.”

This was an encouraging start. A two-point drop on the pain scale within minutes of the procedure is a significant initial improvement. But the most definitive test was to re-palpate the trigger points. The goal of the nerve block is to anesthetize the nerves, so the tenderness at those specific points should be gone.

I went back to the first location, over the supratrochlear nerve. “Does that hurt when I press here?” I asked.

“No,” she said, with a note of surprise.

“Did it hurt there before?”

“Yes. Yes, it did.”

I repeated this process for each of the other three sites:

• Supraorbital nerve: No pain on palpation, where there was sharp pain before.
• Zygomaticotemporal nerve: No pain on palpation.
• Auriculotemporal nerve: No pain on palpation.

This was our diagnostic confirmation. The complete resolution of tenderness at all four nerve sites, combined with the immediate reduction in her overall headache score, demonstrated unequivocally that these four peripheral nerves were the source of her pain. We had successfully intercepted the pain signals.

The immediate drop from a 7/10 to a 5/10 was due to the fast-acting lidocaine. Over the next 30 to 60 minutes, as the longer-acting bupivacaine takes full effect, we would expect to see even further improvement. The ultimate goal is for the block to completely “break” the headache cycle, providing hours of relief and allowing the hypersensitized nervous system to calm down. For many patients, a successful series of blocks can lead to sustained symptom remission, even after the anesthetic wears off.

The Integrative Framework: Where Chiropractic and Functional Medicine Fit In

While nerve blocks provide powerful, immediate relief, they are fundamentally a symptom-management tool. It quiets the screaming nerve but doesn’t necessarily address why the nerve was screaming in the first place. This is where our integrative model, combining chiropractic care and functional medicine, becomes so crucial for long-term success.

The Role of Chiropractic Care: Addressing Biomechanical Roots

The nerves I injected—supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal—are all branches of the trigeminal nerve or are anatomically linked to structures it innervates. The trigeminal system has a deep and intricate connection with the upper cervical spine (the neck). The sensory nucleus of the trigeminal nerve extends down from the brainstem into the upper spinal cord, where it physically overlaps and communicates with sensory nerves from the C1, C2, and C3 spinal levels. This anatomical convergence is known as the trigeminocervical nucleus.

This connection is the physiological basis for cervicogenic headaches, or headaches that originate from the neck. Here is how it works:

• Misalignment (Subluxation): Poor posture, trauma (like whiplash), or degenerative changes can cause misalignments in the vertebrae of the upper cervical spine.
• Nerve Irritation: These misalignments can irritate the delicate nerves exiting the spinal cord at those levels (C1, C2, C3).
• Referred Pain: Because these cervical nerves communicate directly with the trigeminal nucleus, the brain can misinterpret the pain signals originating from the neck as pain in the head and face—the areas supplied by the trigeminal nerve.

As a chiropractor, my role is to assess and correct these biomechanical dysfunctions. For a patient like the one in our case study, a comprehensive chiropractic plan would involve:

1. Spinal Assessment: A thorough examination of her cervical spine to identify areas of restricted motion, vertebral misalignment, and muscle tension.
2. Chiropractic Adjustments: Gentle, specific adjustments to the affected cervical vertebrae to restore proper alignment and mobility. This can directly relieve pressure on the upper cervical nerve roots, reducing the painful input into the trigeminocervical nucleus.
3. Soft Tissue Work: Techniques like myofascial release or trigger point therapy can be applied to the muscles of the neck, shoulders, and head (such as the suboccipital, temporalis, and masseter muscles). Releasing tension in these muscles can reduce direct compression on peripheral nerves (like the auriculotemporal nerve near the TMJ) and decrease the overall mechanical stress on the head and neck.

By correcting the underlying biomechanical faults in the cervical spine, chiropractic care can reduce the frequency and intensity of headache triggers, making procedures like nerve blocks more effective and potentially less necessary over time.

The Role of Functional Medicine: Addressing Systemic Inflammation

Chronic pain is rarely just a local, mechanical issue. Systemic inflammation often fuels it. A functional medicine approach seeks to identify and mitigate the sources of this inflammation. For a headache patient, I would investigate several key areas:

• Diet and Gut Health: Certain foods can be pro-inflammatory (e.g., processed sugar, refined grains, unhealthy fats) and can act as headache triggers for sensitive individuals. Furthermore, an imbalance in gut bacteria or “leaky gut” syndrome (intestinal hyperpermeability) can be a major source of systemic inflammation that contributes to conditions throughout the body, including neuroinflammation and headaches.
• Nutritional Deficiencies: Deficiencies in key nutrients like magnesium, Coenzyme Q10, and B vitamins have been linked to an increased prevalence of headaches and migraines. These nutrients are critical for proper nerve function and mitochondrial energy production.
• Hormonal Imbalances: Fluctuations in hormones like estrogen and cortisol can significantly impact headache patterns.
• Stress and Adrenal Function: Chronic stress can elevate cortisol levels, which can promote inflammation and sensitize the nervous system, lowering the threshold for pain.

A functional medicine plan might include advanced laboratory testing (such as food sensitivity panels, comprehensive stool analysis, or micronutrient testing) to uncover these root causes. Based on the results, interventions could include a personalized anti-inflammatory diet, targeted nutritional supplementation, and lifestyle modifications aimed at stress reduction and improved sleep. By lowering the body’s overall inflammatory burden, we can make the nervous system less reactive and more resilient to pain triggers.

Conclusion: A Synthesized Path to Healing

The case of this 71-year-old woman with Hemicrania Continua beautifully illustrates the power of an integrated, multidisciplinary approach to complex chronic pain. Our journey with her began with a precise medical diagnosis and a targeted intervention—peripheral nerve blocks—to provide immediate and profound relief. This procedure, performed under the guidance of our medical director, Dr. Maria Cardenas, successfully silenced the overactive nerves driving her pain.

But our care does not stop there. The next phase of her treatment will involve chiropractic care to address the biomechanical dysfunctions in her cervical spine that are likely contributing to the irritation of her trigeminal system. Simultaneously, a functional medicine evaluation will help us identify and address any systemic inflammation or nutritional factors that may be perpetuating her pain cycle.

By weaving together the strengths of conventional medicine, chiropractic, and functional medicine, we can offer patients a truly holistic and effective solution. We are not just treating a headache; we are treating a whole person. We break the immediate pain cycle with targeted medical procedures while building a foundation of long-term health and resilience through biomechanical correction and systemic wellness. This is the future of chronic pain management, and it is a privilege to guide our patients on this comprehensive recovery journey.

References

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• [**Janis, J. E., & Barker, J. C. (2018). Migraine surgery: A comprehensive review of the current literature and a proposed algorithm for surgical treatment. Plastic and Reconstructive Surgery, 141(1), 121–134. https://doi.org/10.1097/PRS.0000000000003923**](https://journals.lww.com/plasreconsurg/Abstract/2018/01000/Migraine_Surgery__A_Comprehensive_Review_of_the.20.aspx)
• [**Linde, M., Gaul, C., & Jensen, R. (2020). The pathophysiology of primary headaches – new insights. The Journal of Headache and Pain, 21(1), 22. https://doi.org/10.1186/s10194-020-01093-6**](https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01093-6)
• Page, P. (2011). Cervicogenic headaches: An evidence-led approach to clinical management. International Journal of Sports Physical Therapy, 6(3), 254–266.
• [**Rosen, N. L. (2018). Peripheral nerve blocks for headache disorders. Headache: The Journal of Head and Face Pain, 58(2), 329–341. https://doi.org/10.1111/head.13251**](https://headachejournal.onlinelibrary.wiley.com/doi/abs/10.1111/head.13251)

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