supraorbital neuralgia is a form of localized headache in or above the eyebrow with possible extension in the entire skin region of nerve v1 . supraorbital neuralgia is defined by the international classification of headache disorders by the following diagnostic criteria : paroxysmal or constant pain in the region of the supraorbital notch and the medial aspect of the forehead of the area supplied by the supraorbital nerve . the most important hallmark is the same pain experienced by pressure on the supraorbital notch . in general , trigeminal neuralgia ( tn ) is unilateral affecting the maxillary ( 35% ) , mandibular ( 30% ) , both ( 20% ) , ophthalmic and maxillary ( 10% ) and ophthalmic ( 4% ) branches and all branches of the trigeminal nerve ( 1% ) . a case of tn involving supraorbital neuralgia and infraorbital neuralgia as the incidence of involvement of ophthalmic division and maxillary division is rare . a 35-year - old man with a history of severe ( score of 10 in the verbal numerical scale ) , shock like and throbbing pain in the right v1v2 region , lasting for 510 s that increased on talking , chewing , smiling , with strong breeze and cold water while washing his face since last 67 years . he visited a dental clinic for the same , for which he has undergone extraction of the upper right posterior teeth ( 16 ) . the pain did not subside even he visited various clinics in various places where he was medicated with tablet carbamazepine 200 mg eight hourly . he reported to department of oral and maxillofacial surgery , modern dental college and research centre , indore . after taking a detailed history , the trigger zones were noted which were nasolabial fold , ala of nose , cheek region , supraorbital rim on right side of the face . diagnostic block was given in the infraorbital and supraorbital regions on different occasions for which pain was relieved for several hours . this confirmed the infraorbital and supraorbital neuralgia . to rule out the possible etiology of the neuralgia , mri of cranium the treatment of peripheral neurectomy was planned as he was on already medication since last 6 years . the patient was taken under ga with endotracheal intubation and the supraorbital nerve was exposed via upper eyebrow incision [ figure 1 ] . the nerve was identified and avulsed by twisting the nerve on the artery forcep [ figure 2 ] . then , the infraorbital nerve was exposed through intraoral approach by giving upper vestibular incision from 13 to 16 region [ figure 3 ] . the term neuralgia is used to describe unexplained peripheral nerve pain and the head and neck are the most common sites of such neuralgias . tn is by far the most frequently diagnosed form of neuralgia with mean incidence of 4 per 100,000 populations and mean age of 50 years at the time of examination . tn is usually unilateral affecting the maxillary ( 35% ) , mandibular ( 30% ) , both ( 20% ) , ophthalmic and maxillary ( 10% ) and ophthalmic ( 4% ) branches and all branches of the trigeminal nerve ( 1% ) . tn has long been recognized in the medical literature ; infact , it was described as early as the first century ad in the writings of aretaeus . nicholas andre in 1756 used the term tic doulourex ( painful sensation ) to describe the disorder . fothergill provided a vivid description of tn in 1773 , hence also called as fothergill 's disease . although several hypotheses have been put forward , the cause of tn has not been fully explained in the literature . for most patients , mechanical compression of the tn can occur as the nerve leaves the pons and traverses the subarchonoid space toward meckel 's cave . most commonly , the nerve compressed by a major artery , usually the superior cerebellar artery . when pain is felt in second and third divisions , the usual finding is the compression of the rostral and anterior portions of the nerve by superior cerebellar artery , if the pain is felt in ophthalmic division , the usual finding is compression of the nerve by the anterior inferior cerebellar artery . however , in our case mri showed no compression of the nerve along its course . other causes can be multiple sclerosis , vascular factors  transient ischemia , autoimmune hypersensitivity , secondary to dental diseases such as maxillary sinusitis , third molar infections , trauma and congenital abnormalities in bony canal . lesions with trigeminal ganglion and their rootlets such as central brain lesions , pressure from adjacent cranial structures , tumors of the posterior cranial fossa and vascular compression of nerve root fibers have been reported to be the other causes . tn characterized by paroxysms of severe , lancinating , electric - like bouts of pain restricted to the distribution of the trigeminal nerve . the pain predominantly occurs unilaterally , most commonly on the right side and involves the mandibular and/or maxillary branch or rarely the ophthalmic branch . pain attacks occur spontaneously and also triggered by a nonpainful sensory stimulus to the skin , intraoral mucosa surrounding the teeth and tongue . each attack usually lasts only seconds to minutes , but they may be repeated at short intervals ; consequently , individual attacks can overlap each other and may be described as lingering , painful sensation . attacks can occur at any time and are triggered not only by sensory stimuli to the face , but also by movement of the face . no medical test exists that can be used to diagnose clearly all cases of tn . the diagnosis of tn rests on the clinician 's ability to recognize a distinctive series of signs and symptoms that define this disorder . the criteria emphasize five major clinical features that in essence , define the diagnosis of tn . they are : 
 the pain is paroxysmal.the pain may be provoked by light touch to the face ( trigger zone).the pain is confined to trigeminal distribution.the pain is unilateral.the clinical sensory examination is normal . the pain may be provoked by light touch to the face ( trigger zone ) . diagnostic criteria are defined by the international association for the study of pain ( iasp ) and by the international classification of headache disorders / international headache society ( ichd / ihs ) and include : 
 paroxysmal episodes lasting from a fraction of a 1 sec . to 2 min . , affecting one or more divisions of the trigeminal nerve.the pain has at least one of the following characteristics : 
 a)severe , sudden , superficial , or stabbing ; andb)initiated by trigger factors or trigger points . episodes are similar among patients.patients do not have clinically evident neurologic changes.it is not attributed to other disorders . the pain has at least one of the following characteristics : 
 a)severe , sudden , superficial , or stabbing ; andb)initiated by trigger factors or trigger points . severe , sudden , superficial , or stabbing ; and initiated by trigger factors or trigger points . the most common disorders involved in the differential diagnosis include bursts of headaches , dental pain , giant cell arteritis , glossopharyngeal nerve neuralgia , intracranial tumor , migraine , multiple sclerosis , otitis media , paroxysmal hemicrania , postherpetic neuralgia , sinusitis , sunct headache ( short - lasting , unilateral , neuralgiform pain with conjunctival injection and tearing ) , temporomandibular joint syndrome and tn . initially , administration of anticonvulsant drugs was the treatment of choice . there are several factors that can affect a treatment plan , including the patient 's age , life expectancy , associated medical and psychiatric conditions , compliance with medical therapy and tolerability of adverse effects of drugs . invasive procedures ( peripheral neurectomy , radiofrequency thermocoagulation at gasserian ganglion , retrogasserian rhizotomy , medullary tractotomy , midbrain tractotomy and intracranial nerve decompression ) are usually reserved for those patients who are unable to obtain relief with medical management or experience unacceptable adverse effects from the use of pharmacologic treatments . supraorbital neuralgia is a rare disorder clinically characterized by the following triad : 
 forehead pain in the area supplied by the supraorbital nerve , without side shift;tenderness on either the supraorbital notch or traject of the nerve ; andabsolute , but transitory relief of symptoms upon supraorbital nerve blockade . forehead pain in the area supplied by the supraorbital nerve , without side shift ; tenderness on either the supraorbital notch or traject of the nerve ; and absolute , but transitory relief of symptoms upon supraorbital nerve blockade . in addition , there may be signs and symptoms of sensory dysfunction ( hypoesthesia , paresthesia ) and typical  neuralgic features ( lightning pain and exteroceptive precipitating mechanisms ) . the hallmark of supraorbital neuralgia is localized pain in or above the eyebrow ( sometimes extending into the parietotemporal scalp region ) . although etiology and pathogenesis of supraorbital neuralgia are largely unknown , entrapment of the supraorbital nerve at its outlet , trauma to the face , such as when the head hits the windshield or after a punch to the face are thought to be the causative factor and neuralgic pain . the headache might not present for many years until the scar cicatrix tightens enough around the nerve to finally cause entrapment . supratrochlear nerve in this region can be injured by poor - fitting eyeglasses , presenting as a more midline forehead pain . entrapments of first division of the trigeminal nerve can cause unilateral or bilateral throbbing headaches , often just before menses or triggered by bright lights that cause squinting . the proposed treatment is an injection of 2 ml of 2% lidocaine , 1:60,000 adrenalin in the supraorbital canal , which relieves and mostly obviates the pain in 80% of the patients over a considerable time of span . generally , there will be lack of , or only minor benefit from drug treatment , including carbamazepine and indomethacin . there will clearly be tenderness over the supraorbital nerve , especially at its outlet and in some subjects occasionally , a slight local loss of sensation . the persistence of protracted unilateral forehead / ocular pain , tenderness over the nerve and repeated blockade effect strongly suggests the diagnosis and patient 's willingness for surgical treatment . complications reported are local hemorrhage , transient diplopia , transient anesthesia of supraorbital skin , mostly lasting only for few days . correct diagnosis of supraorbital neuralgia is critical in choosing therapy . for persistent or recurrent pain , acupuncture , injection of phenol / glycerol or botulism toxin , neurolysis and root section of the trigeminal nerve are methods that have been successfully employed to treat this condition . consensus on the best treatment for tn , clinical or surgical , does not exist .