Nerve Block Management Solutions for the Hemicrania Continua

Explore effective strategies for hemicrania continua headaches, including nerve block management, to find relief from chronic pain.

Abstract

This educational post explores a multifaceted approach to managing complex headache disorders, focusing on hemicrania continua through an integrative and functional medicine lens. We will delve into a clinical case of a 71-year-old patient presenting with a severe, right-sided headache, demonstrating the diagnostic process and application of peripheral nerve blocks as an effective therapeutic intervention. This discussion will detail the specific anatomical targets—the supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal nerves—and the rationale for their blockade using a combination of lidocaine and bupivacaine. We will also explain how this procedure fits within a broader, collaborative care model. This model integrates the specialized skills of chiropractic (Dr. Alex Jimenez) and internal medicine (Dr. Maria Guadalupe Cardenas), alongside functional medicine principles, to provide comprehensive, patient-centered care. We will explore the underlying neuro-inflammatory mechanisms of chronic headaches and how an integrative strategy, combining immediate symptom relief with long-term foundational health improvements, offers a robust pathway to lasting wellness.

Introduction to Our Collaborative Care Model at Injury Medical Clinic

Hello, I am Dr. Alex Jimenez. With a deep passion for understanding the intricate workings of the human body, I have dedicated my career to a path of continuous learning, earning credentials as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN), a board-certified Family Nurse Practitioner (FNP-BC), a Certified Functional Medicine Practitioner (CFMP), and an Institute for Functional Medicine Certified Practitioner (IFMCP), among others. My mission has always been to bridge gaps between medical disciplines and offer patients the most comprehensive and effective care possible.

Here at Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, in El Paso, Texas, we have built a practice on the foundational principle of integrative care. This means we don’t just treat symptoms; we treat the whole person—their biochemistry, structure, lifestyle, and unique health journey. A cornerstone of this model is our collaboration with esteemed medical professionals who share this vision.

I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is board-certified in Internal Medicine and brings over 40 years of invaluable clinical experience to our team. She serves as our Medical Director and Collaborative Physician, providing essential medical oversight and diagnostic expertise. This multidisciplinary partnership between a Doctor of Chiropractic with advanced practice nursing and functional medicine credentials (myself) and a seasoned Internist (Dr. Cardenas) is the bedrock of our clinic. It allows us to seamlessly integrate chiropractic adjustments, advanced rehabilitation, functional medicine protocols, personal injury care, and, when necessary, medical procedures like the nerve blocks we will discuss today. This structure ensures that every patient receives a tailored treatment plan that is not only effective but also safe, with all aspects of their care considered from multiple professional perspectives.

A Clinical Encounter: The Challenge of Hemicrania Continua

Today, on September 1, 2026, I had the privilege of seeing a 71-year-old woman who presented with a challenging and persistent condition. She was experiencing a severe, right-sided headache that was relentless. In medical terms, her presentation is characteristic of hemicrania continua, a type of primary headache disorder known for its continuous, unilateral pain that can have periods of exacerbation. When she came into my examination room, she rated her pain as a seven out of ten—a significant level of discomfort that was clearly impacting her quality of life.

My initial role, combining my skills in physical diagnosis and neurology, was to identify the source of her pain precisely. A thorough physical examination is paramount. For headache patients, this involves more than just asking about the pain; it requires a hands-on approach to palpate the structures of the head, neck, and face to locate the epicenters of tenderness and dysfunction.

The Diagnostic Examination: Pinpointing the Pain Triggers

During my examination of this patient, I focused on palpating the pathways of several key superficial nerves of the face and scalp. These nerves are branches of the trigeminal nerve (cranial nerve V), which is the principal sensory nerve of the face. Irritation or sensitization of these terminal branches can drive facial pain and headaches. My goal was to see if I could reproduce her specific pain by applying gentle pressure over these nerves.

The exam results were clear and definitive. I identified four specific points of exquisite tenderness that corresponded directly to the anatomical locations of four peripheral nerves:

• The Supratrochlear Nerve: Located superior and medial on the forehead, just above the inner part of the eyebrow. When I applied gentle pressure here, she immediately confirmed, “Yes,” that was a point of significant pain. This nerve provides sensation to the skin of the lower, central forehead.
• The Supraorbital Nerve: Found slightly more lateral, exiting the skull through a small notch or foramen in the supraorbital rim (the bone just above the eye). Pressing here elicited another strong, affirmative “Yes,” confirming it as a second pain generator. This nerve is a larger branch and supplies sensation to the forehead, scalp, and upper eyelid.
• The Zygomaticotemporal Nerve: This smaller nerve emerges on the side of the head, in the temple area, after passing through the zygomatic bone (cheekbone). When I palpated this region, she again confirmed it was a source of her pain. It provides sensation to the skin over the temple.
• The Auriculotemporal Nerve: Located just in front of the ear, this nerve runs superiorly alongside the superficial temporal artery. Palpation in this area triggered the fourth and final point of tenderness. This nerve supplies sensation to the side of the head, the ear, and the temporomandibular joint (TMJ) area.

Having identified these four distinct “trigger points” corresponding to specific nerves, I had a clear working diagnosis. The patient’s continuous, one-sided headache was being driven, or at least significantly amplified, by the irritation and sensitization of these peripheral nerves. This is common in chronic headache conditions, where the nervous system becomes “wound up,” a process known as central sensitization. However, by targeting the peripheral sources, we can often “calm down” the entire system.

This diagnostic clarity paved the way for a targeted therapeutic intervention: a series of peripheral nerve blocks aimed at silencing these overactive nerves and, hopefully, breaking the pain cycle.

The Therapeutic Strategy: Peripheral Nerve Blocks

A peripheral nerve block is a procedure in which a local anesthetic is injected near a specific nerve or group of nerves to interrupt pain signal transmission temporarily. It’s a highly effective tool for both diagnostic and therapeutic purposes. Diagnostically, if blocking a nerve provides immediate pain relief, it confirms that the nerve is indeed involved in the pain pathway. Therapeutically, the block can provide hours, days, or even longer periods of relief, breaking the vicious cycle of pain and inflammation.

The Anesthetic Cocktail: A Dual-Action Approach

For this procedure, I chose a specific combination of anesthetic agents designed for both rapid onset and extended duration of action. The mixture consisted of:

• 0.5% Lidocaine with Epinephrine: Lidocaine is a fast-acting anesthetic, meaning it starts working very quickly—often within minutes. This is crucial for providing the patient with immediate feedback and relief. The addition of epinephrine is strategic. Epinephrine is a vasoconstrictor, meaning it narrows blood vessels in the injection area. This has two key benefits:

1. 1. It reduces local bleeding at the injection site.
   2. More importantly, it slows down the rate at which the anesthetic is absorbed into the bloodstream. This keeps lidocaine concentrated around the nerve longer, prolonging its effect.

1. Bupivacaine: In contrast to lidocaine, bupivacaine is a long-acting anesthetic. While it takes longer to take effect, its pain-blocking properties can last for many hours.

Combining these two agents creates a synergistic effect. The lidocaine provides a rapid “knockdown” of the pain, while the bupivacaine “takes over” to provide sustained relief long after the initial effect of the lidocaine would have worn off. This combination is ideal for treating acute exacerbations of chronic pain, as it aims not just to numb the area temporarily but to break the underlying pain cycle completely.

The Procedure: Precision, Safety, and Patient Comfort

Performing injections on the face, especially near the eyes, requires meticulous care, precision, and a focus on patient safety and comfort.

1. Preparation and Marking:

The first step was to mark the four injection sites precisely. While I had identified them through palpation, I used the retracted tip of a ballpoint pen to make very light ink marks on the skin. It is important not to apply too much pressure, as this can be uncomfortable and irritate the tissue. After marking, I thoroughly prepped the skin with Betadine, an antiseptic solution, to minimize the risk of infection.

2. Injection Technique:

I used a very fine 30-gauge, half-inch needle. The small diameter of this needle helps to minimize the pain of the injection itself. For each of the four sites, I planned to inject a total of one milliliter (1 mL) of the anesthetic mixture.

Typically, for injections in other parts of the body, I might use a “freeze spray” (like ethyl chloride) to numb the skin just before the needle stick. However, working so close to the eyes makes this impractical and unsafe. In this situation, the brief sting of the fine needle is far less uncomfortable and safer than risking spray entering the eye.

3. Safeguarding the Orbit:

For the first two injections—the supratrochlear and supraorbital nerves—a critical safety measure is to protect the orbit (the eye socket). Local anesthetic should not enter the orbital space, as it can affect the muscles that control eye movement and cause temporary vision changes.

To prevent this, I placed my thumb firmly against the orbital rim (the bony ridge of the eye socket) just below the injection site. As I slowly injected the 1 mL of fluid, my thumb acted as a physical barrier, or a bolster, preventing the anesthetic from tracking downward into the orbital area. I felt the fluid pressure building under my thumb, which was a good sign—it confirmed the anesthetic was spreading through the intended subcutaneous tissue planes of the forehead and not migrating toward the eye.

4. The Injection Sequence:

• Supratrochlear Nerve: I started with the most medial point. I advanced the needle until I felt it gently touch the bone (the frontal bone). This landmark confirmed I was at the correct depth. I then slightly withdrew the needle so the tip was just off the periosteum (the membrane covering the bone) and began the injection. Before injecting, I aspirated—pulled back on the plunger—to ensure the needle tip was not inside a blood vessel. Then, I slowly and steadily injected the 1 mL of solution.
• Supraorbital Nerve: I repeated the same process for the supraorbital nerve, again using my thumb as a protective bolster against the orbital rim. Touch bone, aspirate, and inject. The patient tolerated this well.
• Zygomaticotemporal Nerve: Moving to the temple, I located the third target. Here, a crucial safety consideration is the superficial temporal artery, a large artery that runs in this area. It is vital not to inject directly into an artery. Therefore, after advancing the needle to the bone (the zygomatic bone), I was especially careful to aspirate thoroughly to ensure no blood return. Seeing none, I proceeded with the injection. For this site, and the next, bolstering with my thumb was unnecessary because we were well away from the orbit.
• Auriculotemporal Nerve: Finally, I targeted the area just anterior to the ear. Again, the technique was consistent: advance the needle to gently touch the temporal bone, withdraw slightly, aspirate to check for vessel placement, and inject the final 1 mL of anesthetic.

The entire procedure, from marking to the final injection, took only a few minutes. I checked in with the patient throughout, and she confirmed that while she felt a “little pinch on a couple of them,” the overall experience was not bad and certainly less than she had feared.

Immediate Results and Post-Procedure Assessment

With the injections complete, the most important question was: did it work?

It’s important to remember that the full effect, especially from the long-acting bupivacaine, can take 30 to 60 minutes to develop. However, the rapid action of lidocaine often provides an immediate indication of success.

Before the procedure, the patient had rated her headache a 7 out of 10. Just moments after the final injection, I asked her to re-evaluate her pain. “I think it’s better,” she replied. “More like a five.”

This was a very encouraging initial result—an immediate two-point drop on the pain scale. But I wanted more objective confirmation. I went back and re-palpated the four nerve sites that had been exquisitely tender just minutes before.

• “Over this nerve, the supratrochlear nerve, does that hurt now when I press?” She answered, “No.” I asked, “Did it hurt before?” “Yes, it did,” she confirmed.
• “How about here, over the supraorbital nerve?” Again, the answer was “No.” It had been painful before.
• I repeated this for the zygomaticotemporal and auriculotemporal nerve sites. For both, the pre-procedure tenderness was completely gone.

This is a classic positive finding for a successful nerve block. Not only was her subjective headache score improving, but the objective sign of allodynia (pain from a stimulus that is not normally painful, like gentle pressure) over the nerves had been completely resolved. This confirmed that we had successfully anesthetized the target nerves.

The goal now was to see this improvement continue. I hoped that as the bupivacaine took full effect, her pain would continue to decrease, hopefully to zero, and that the block would not only provide hours of relief but would effectively “break” the headache cycle, leading to a sustained period of being pain-free.

The Role of Integrative Chiropractic Care in Headache Management

While procedures like nerve blocks are powerful tools for acute pain relief, they are one piece of a much larger puzzle. At our clinic, our goal is not just to manage flare-ups but to address the root causes of the patient’s condition and improve overall health and resilience. This is where integrating chiropractic care, functional medicine, and rehabilitation becomes essential.

Structural Integrity and Neurological Function

As a Doctor of Chiropractic, my primary focus is the relationship between the body’s structure—particularly the spine—and the nervous system’s function. The nerves I injected in the face are all branches of the trigeminal nerve. The trigeminal nucleus, the “control center” for this nerve, extends down into the upper cervical spine (the neck), where it has a direct anatomical and functional relationship with the sensory nerves of the C1, C2, and C3 spinal levels. This is known as the trigemino-cervical complex.

This anatomical convergence is critically important. It means dysfunction in the upper neck—such as vertebral misalignments (subluxations), muscle tension, or joint inflammation—can directly irritate this complex. This irritation can then refer to the head and face as pain, mimicking or exacerbating conditions like hemicrania continua or migraine.

Clinical Observations from My Practice:

In my years of practice, I have consistently observed a strong correlation between upper cervical dysfunction and the prevalence and intensity of chronic headaches. Patients often present with restricted neck motion, palpable muscle tension in the suboccipital muscles (the small muscles at the base of the skull), and forward head posture. These structural issues place chronic mechanical strain on the trigemino-cervical complex, creating persistent neurological irritation that can make a person more susceptible to headaches.

How Chiropractic Adjustments Help

Chiropractic adjustments, especially those focused on the cervical spine, restore proper motion and alignment to the spinal joints. By delivering a precise, gentle force to a restricted joint, we can:

• Improve Joint Mechanics: Restore normal movement and reduce mechanical stress on surrounding tissues.
• Reduce Nerve Irritation: By correcting misalignments, we can decrease the direct and indirect irritation of the spinal nerves and the trigemino-cervical complex.
• Decrease Muscle Tension: A properly aligned spine allows the surrounding muscles to relax. Adjustments can help break the cycle of pain and muscle spasm.
• Modulate Pain Signals: Sensory input from a chiropractic adjustment can help “gate” or override pain signals traveling through the spinal cord, providing an analgesic effect.

For a patient like the one in our case study, an integrative plan would involve using the nerve blocks for immediate, powerful relief, and then following up with a course of chiropractic care. Once her acute pain is controlled, we can begin addressing the underlying structural imbalances in her neck that may be contributing to sensitization of her trigeminal system. This combination attacks the problem from two angles: a “top-down” approach with the nerve block silencing the peripheral pain signals, and a “bottom-up” approach with chiropractic care addressing the central sensitizing factors in the cervical spine.

Beyond the Adjustment: A Functional Medicine Perspective

Our integrative model goes even deeper. As a functional medicine practitioner, I also investigate the biochemical and metabolic factors that can contribute to chronic pain and inflammation. For a headache patient, this might involve:

• Identifying Inflammatory Triggers: We might use advanced testing to look for food sensitivities, gut dysbiosis (an imbalance in gut bacteria), or hidden infections that can create systemic inflammation and make the nervous system more reactive.
• Assessing Nutrient Deficiencies: Deficiencies in nutrients like magnesium, Coenzyme Q10, and B vitamins can contribute to headache disorders.
• Evaluating Hormonal Imbalances: Fluctuations in hormones can be a major trigger for headaches, especially in women.
• Managing Stress and Adrenal Function: Chronic stress leads to dysregulation of the HPA (hypothalamic-pituitary-adrenal) axis, which can promote inflammation and lower the pain threshold.

By identifying and addressing these underlying factors through targeted nutritional interventions, supplements, and lifestyle modifications, we can help to lower the patient’s overall inflammatory burden and make their nervous system less prone to triggering a headache attack. This is the essence of building long-term health and resilience, moving beyond the cycle of simply managing symptoms.

Conclusion: A Symphony of Care

This case of a 71-year-old woman with hemicrania continua illustrates the power of an integrative, multidisciplinary approach. The peripheral nerve block, performed under the authority of my APRN license and in collaboration with our Medical Director, Dr. Cardenas, provided immediate and significant relief from her debilitating pain. It served as a powerful tool to break an acute pain cycle.

However, true healing and long-term management come from weaving this intervention into a broader care plan. This includes:

• Medical Oversight (Dr. Cardenas): Ensuring an accurate diagnosis and appropriate management of any underlying medical conditions.
• Targeted Interventions (Dr. Jimenez, APRN): Using procedures like nerve blocks for rapid symptom control.
• Structural and Neurological Care (Dr. Jimenez, DC): Using chiropractic adjustments to address foundational issues in the spine that contribute to neurological sensitization.
• Biochemical and Lifestyle Management (Dr. Jimenez, CFMP/IFMCP): Using functional medicine to reduce systemic inflammation and build resilience from the inside out.

This synergistic model allows us to offer patients the best of multiple worlds. We can extinguish the “fire” of acute pain while simultaneously rebuilding the foundation of the house to prevent future fires. It is a patient-centered, evidence-based journey toward not just feeling better, but being truly well.

References

• Choi, H. J., & Park, K. Y. (2016). Supratrochlear nerve block for patients with intractable migraine. The Journal of Craniofacial Surgery, 27(4), e382-e384. https://journals.lww.com/jcraniofacialsurgery/abstract/2016/06000/supratrochlear_nerve_block_for_patients_with.49.aspx
• Goadsby, P. J., Holland, P. R., Martins-Oliveira, M., Hoffmann, J., Schankin, C., & Akerman, S. (2017). Pathophysiology of migraine: A disorder of sensory processing. Physiological Reviews, 97(2), 553–622. https://doi.org/10.1152/physrev.00034.2015
• Noseda, R., & Burstein, R. (2013). Migraine pathophysiology: Anatomy of the trigeminovascular pathway and associated brain-stem nuclei; functional neuroimaging; and novel therapeutics. Pain, 154(Suppl 1), S44–S53. https://doi.org/10.1016/j.pain.2013.07.021
• Piagkou, M., Tasigiorgos, S., & Lappas, D. (2012). The supratrochlear nerve: a meta-analysis of its anatomical variations and its clinical significance. Journal of Clinical Anatomy, 25(6), 661-671. https://doi.org/10.1002/ca.22013
• Tfelt-Hansen, P., & Jensen, R. H. (2012). Management of migraine. The Lancet Neurology, 11(8), 774-786. https://doi.org/10.1016/S1474-4422(12)70150-1

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