Nerve Block Management Tips for Hemicrania Continua Headaches

Learn about hemicrania continua headaches with nerve block management and find relief with proven techniques and approaches.

Abstract

In this comprehensive educational post, I, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, present a clinically detailed, first-person account of a real-world case of right-sided headache in a 71-year-old patient with hemiplegia continua. I guide the reader through the neuroanatomy of the supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal nerves, and demonstrate how targeted peripheral nerve blocks can meaningfully reduce pain intensity. This case is contextualized within our multidisciplinary practice: Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, where I collaborate closely with Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), our Medical Director and Collaborative Physician with 40+ years of internal medicine experience. Together, we integrate chiropractic care, internal medicine oversight, functional medicine, personal injury management, and rehabilitation—supported by modern evidence-based research methods, protocols, and clinical analytics.

The post outlines:

• Detailed patient evaluation and clinical reasoning behind nerve-block injections with lidocaine (with epinephrine) and bupivacaine
• Neurological safety considerations and injection techniques near the orbit and temporal region
• Physiological mechanisms of nociception, neuropeptides, and trigeminal activation relevant to craniofacial headaches
• How integrative chiropractic care fits into headache management, including cervical spine mechanics, myofascial contributions, and autonomic modulation
• Structured, stepwise multidisciplinary protocols with outcomes tracking, patient education, and risk mitigation strategies
• A long-form, deeply elaborated exploration of the pathophysiology, clinical indications, and evidence base supporting peripheral nerve blocks in headache care.

By presenting this case and the surrounding framework, I aim to make complex neuroanatomy and multimodal pain management approachable and actionable for patients, clinicians, and learners seeking modern, patient-centered, evidence-based care.

My Role, Our Team, and the Integrative Model

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso-based practice—Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic)—I work hand in hand with Dr. Maria Guadalupe Cardenas, MD (Internal Medicine), who has served patients for over four decades and brings seasoned clinical judgment to every complex case we manage. Dr. Cardenas is our Medical Director and Collaborative Physician, guiding medical oversight, safety, and diagnostic precision within our multidisciplinary team. This integrative setup is common in injury care clinics and functional-integrative centers, where coordinated care ensures patients receive comprehensive and safe interventions.

• Our shared goal is to:

• • Provide evidence-based pain relief
  • Uncover the root causes of recurrent headaches
  • Integrate chiropractic adjustments, soft tissue care, physiologic nerve blocks, and functional medicine strategies
  • Prevent medical complications with robust oversight and monitoring
  • Educate patients about the mechanisms and expectations of treatment

In this post, I will recount a patient experience and the clinical reasoning behind each step, connecting procedural details to the broader system of integrative chiropractic care and internal medicine guidance.

The Patient’s Story: Right-Sided Headache with Hemiplegia Continua

The patient is a 71-year-old woman who presented the morning of the visit with a right-sided headache. She also has hemiplegia continua, a rare neurological condition characterized by persistent, often fluctuating motor deficits on one side of the body. While hemiplegia continua can present many challenges, our immediate objective was to relieve her focal headache intensity and determine whether peripheral nerve blocks could break the pain cycle.

• Her self-reported pain score was 7/10 before the procedure.
• The headache was focal, with tenderness over specific craniofacial nerve exit points:

• • Supratrochlear nerve
  • Supraorbital nerve
  • Zygomaticotemporal nerve
  • Auriculotemporal nerve

These anatomical landmarks are commonly implicated in craniofacial neuralgias, migraine variants, tension-type headaches, and post-traumatic headache patterns, particularly when pericranial muscle tension or local nerve sensitization amplifies nociception.

Locating the Pain: Neuroanatomy in the Physical Examination

As I examined her, I palpated and gently assessed four focal regions. She confirmed reproducible tenderness and pain at each site, which strongly suggested peripheral nerve involvement:

• Supratrochlear nerve: Medial superior orbit, near the brow. This nerve arises from the frontal branch of the ophthalmic division (V1) of the trigeminal nerve, contributing to sensation of the medial forehead and scalp. Inflammation or compression here can radiate into the medial supraorbital region.
• Supraorbital nerve: Exits through the supraorbital notch/foramen along the superior orbital rim, supplying the central forehead and anterior scalp. This nerve is a frequent target for migraine and tension-type headache nerve blocks.
• Zygomaticotemporal nerve: Branch of the maxillary division (V2) via the zygomatic nerve; emerges in the temporal region. It can be involved in headaches with temporal and lateral frontal distribution.
• Auriculotemporal nerve: From the mandibular division (V3), coursing anterior to the ear and over the temporal region. It provides sensation to parts of the ear, temporal scalp, and TMJ region; often implicated in temporal headaches and TMJ-related pain.

By lightly marking tender sites with minimal pressure, I planned for safe, accurate injection placement. Working near the orbit and temporal artery demands precision, gentle technique, and anatomical knowledge.

The Injection Plan: Evidence-Based Peripheral Nerve Blocks

We planned to inject a mixture of local anesthetics:

• Half 5% lidocaine with epinephrine: Lidocaine offers rapid sodium-channel blockade, reducing nociceptive transmission; epinephrine helps vasoconstrict, decreasing bleeding and prolonging local effect.
• Half bupivacaine: Provides longer-lasting analgesia via sustained sodium-channel blockade.

Total volume: 1 mL per site.

Needle choice: 30-gauge, half-inch needle to minimize patient discomfort and improve control in delicate facial planes.

Sterility: Betadine prep for skin asepsis at each marked location.

Safety in periorbital areas:

• I positioned my thumb along the orbital rim to prevent anesthetic migration into the orbital soft tissues.
• I aspirated before injection to avoid intravascular administration, which is especially important in the temporal region due to nearby vasculature.

Rationale:

• Blocking peripheral nerves interrupts afferent pain signals and may modulate local release of neuropeptides (e.g., CGRP, substance P), dampening neurogenic inflammation and reducing central sensitization.
• These blocks offer both diagnostic value (confirming peripheral nerve involvement) and therapeutic benefit (providing relief and informing longer-term strategies).

The Procedure: Step-by-Step Technique and Patient Experience

I readied the mixture and confirmed all equipment:

• 30-gauge half-inch needle
• Proper antisepsis with Betadine
• Gentle ink marking
• Patient consent and safety checks

Working close to the eyes means we avoid freezing sprays that might compromise ocular safety or alter perception of needle placement. Direct injection is typically less uncomfortable than prolonged topical analgesia in that area.

• Supratrochlear nerve injection:

• • I placed my thumb under the orbital rim to stabilize and prevent downward spread.
  • Gently advanced the needle to touch bone, retracted slightly, aspirated, and injected 1 mL.
  • Patient felt pressure but tolerated well.

• Supraorbital nerve injection:

• • Again, thumb support at the orbital rim; contacted bone at the supraorbital notch
  • Aspirated—no blood return.
  • Injected 1 mL in the same manner.
  • Noted pressure; ensured no inferior migration.

• Zygomaticotemporal nerve injection:

• • Advanced to contact bone in the temporal region.
  • Aspirated carefully to ensure it was not in the temporal artery.
  • Injected 1 mL; thumb bolstering was not necessary here.

• Auriculotemporal nerve injection:

• • Same gentle approach; bone contact, slight withdrawal, aspiration, then 1 mL injection.

At the end, I asked about pain. She reported:

• The injections were not very painful—only mild pinches at a couple of sites.
• Immediate reassessment showed her headache intensity dropped from 7/10 to 5/10.

On palpating the previously tender nerves:

• Supratrochlear: No pain on palpation; previously tender.
• Supraorbital: No pain on press; previously tender.
• Auriculotemporal: No pain on press.
• Zygomaticotemporal: No pain on press.

We planned to observe her over the next 30 to 60 minutes and expected relief to continue for hours, possibly breaking the headache cycle.

Why Peripheral Nerve Blocks Help Headaches: Physiological Deep Dive

Peripheral nerve blocks are grounded in a nuanced understanding of nociception and neuroinflammation. Headache disorders—even tension and migraine—often involve peripheral and central pathways:

• Peripheral Sensitization:

• • Chronic muscle tension, fascial adhesions, or local irritation around nerve exit points can lower nociceptor thresholds.
  • Anesthetic blockade reduces sodium influx in Aδ and C fibers, halting action potential propagation and interrupting pain signals at their source.

• Neurogenic Inflammation:

• • Trigeminal activation can release CGRP, substance P, and neurokinin A, leading to vasodilation, plasma extravasation, and mast cell activation.
  • Local anesthetics may blunt this release and reduce the perivascular inflammatory milieu.

• Central Sensitization:

• • Persistent peripheral input can amplify dorsal horn neuron responsiveness and higher-order pain networks.
  • Interrupting peripheral input can reset or dampen central sensitization, reducing overall pain experience.

• Autonomic Modulation:

• • Craniofacial nerves have intimate connections with autonomic pathways. Reducing nociceptive drive may decrease sympathetic overactivity, improve vascular tone, and reduce dysautonomia-related headache components.

• Myofascial Contribution:

• • Muscles like frontalis, temporalis, and masseter, along with fascia layers, can compress or irritate nerve branches.
  • Nerve blocks alleviate immediate pain, allowing subsequent manual therapy or rehabilitative care to normalize biomechanics.

These mechanisms are well supported by clinical experience and a growing body of literature on occipital, supraorbital, auriculotemporal, and other cranial nerve blocks used in headache management (e.g., migraine, cluster, tension-type, post-traumatic headaches) (see references).

Integrative Chiropractic Care: Bridging Mechanics, Neurology, and Function

Our integrative approach places chiropractic care alongside medical and functional strategies to address the mechanical and neurological elements of headaches:

• Cervical Spine Alignment:

• • Upper cervical segments (C0-C2) influence the trigeminocervical complex. Dysfunction can trigger referred craniofacial pain.
  • Carefully applied, evidence-informed adjustments improve joint mechanics, reduce nociceptive input, and modulate muscle tension.

• Myofascial Release:

• • Addressing trigger points in upper trapezius, levator scapulae, temporalis, masseter, and suboccipital muscles decreases abnormal mechanical stress on cranial nerves.
  • Techniques include instrument-assisted soft tissue mobilization, active release, and PNF stretching.

• Postural and Ergonomic Coaching:

• • Cervicogenic contributions often arise from forward head posture, screen time, and poor ergonomics.
  • We integrate tailored programs to restore neutral spine alignment and reduce compressive loads on cranial nerve pathways.

• Autonomic Regulation:

• • Gentle mobilizations, breathing retraining, and vagal tone support through positional and respiratory interventions can decrease sympathetic drive and improve headache thresholds.

• Rehabilitative Exercise:

• • Cervical deep flexor activation, scapular stabilization, and TMJ mechanics help normalize kinetic chains associated with craniofacial pain.
  • We progress patients through graded activity to rebuild resilience.

Peripheral nerve blocks complement these mechanical interventions, providing immediate pain reduction that enables better tolerance and effectiveness of chiropractic and rehabilitative work.

Internal Medicine Oversight: Dr. Cardenas’ Role in Safety and Systems Thinking

Working under the medical direction of Dr. Maria Guadalupe Cardenas, MD, we ensure:

• Appropriate patient selection for nerve blocks, considering comorbidities (e.g., cardiovascular disease, diabetes, anticoagulant use).
• Medication safety: Dosing, mixtures, and contraindications (e.g., allergies, epinephrine cautions).
• Monitoring for adverse effects: Local hematoma, intravascular injection risks, systemic local anesthetic toxicity.
• Diagnostics: Identifying complex contributors—hypertension, sleep apnea, thyroid dysfunction, electrolyte imbalances, medication overuse, and dehydration—that can exacerbate headaches.
• Follow-up strategy: Structured reevaluation and integration with functional and rehabilitative plans.

Dr. Cardenas’ four decades of experience provide critical clinical insight, ensuring our integrative approach balances innovation with tried-and-true medical prudence.

Functional Medicine Layer: Root-Cause Exploration

Functional medicine complements our interventions by addressing metabolic, inflammatory, and lifestyle drivers:

• Inflammation and Diet:

• • Anti-inflammatory nutrition: Higher omega-3 intake, lower processed foods, identification of migraine triggers (e.g., aged cheeses, nitrates, alcohol).
  • Micronutrients: Magnesium, riboflavin (B2), CoQ10, and vitamin D support neurovascular stability.

• Glycemic Control:

• • Fluctuating blood sugar levels can precipitate headaches. Stabilizing with balanced macros reduces triggers.

• Sleep Optimization:

• • Addressing sleep apnea, insomnia, and circadian misalignment improves neurovascular regulation.

• Stress and Autonomic Balance:

• • Techniques: HRV training, mindfulness, breathwork, biofeedback.

• Hormonal and Thyroid Considerations:

• • Perimenopausal and postmenopausal shifts can alter headache patterns. We assess thyroid function, adrenal stress, and sex hormones when clinically indicated.

These foundational elements increase the durability of headache relief and reduce recurrence.

Personal Injury and Rehabilitation Integration

In personal injury contexts, headaches may be due to:

• Whiplash-related cervical strain
• TMJ dysfunction
• Myofascial injuries
• Subclinical concussion or post-traumatic headache

Our integrated program includes:

• Imaging where necessary (e.g., MRI, CT for red flags)
• Neurocognitive screening for concussion
• Chiropractic adjustments tied to injury mechanics
• Soft tissue therapy for scar tissue and adhesions
• TMJ rehabilitation with bite assessment and coordinated dental referrals when appropriate
• Nerve blocks for focal relief to enable progression through therapy

Clinical Observations: Insights from Practice

Across years of care documented through our platforms, including WellnessDoctorRX and professional profiles, we consistently observe:

• Patients with focal craniofacial tenderness over supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal nerves often respond to nerve blocks, with improved tolerance for chiropractic care, soft tissue release, and rehabilitation
• Combining immediate analgesia with medium-term mechanical correction yields better sustained outcomes than either approach alone.
• Precision anatomical palpation, patient-specific dose adjustments, and thoughtful follow-up enhance block success by addressing underlying contributors.

These observations dovetail with published findings supporting nerve blocks in refractory headache cases and multimodal management frameworks.

Stepwise Protocol: From Evaluation to Follow-Up

Our method follows a structured flow:

1. Initial Assessment

• • History: onset, triggers, patterns, aura, autonomic symptoms.
  • Examination: cranial nerve palpation, cervical mechanics, TMJ function, neurological screening.
  • Red flags: sudden thunderclap headache, focal deficits beyond baseline hemiplegia continua, systemic symptoms.

• Medical Oversight

• • Review medications, allergies, comorbidities.
  • Determine suitability for local anesthetic with epinephrine.
  • Obtain consent and explain risks/benefits.

• Injection Technique

• • Sterile prep; gentle marking.
  • 30-gauge half-inch needle; contact bone, slight withdrawal, aspirate, inject.
  • Orbital rim thumb support to prevent migration.

• Immediate Reassessment

• • Pain scale response.
  • Palpation of prior tender points.
  • Observation 30–60 minutes.

• Adjunctive Care

• • Chiropractic adjustments for cervical biomechanics.
  • Myofascial release for pericranial muscles.
  • Breathing and posture interventions.

• Functional Medicine Measures

• • Nutrition modification.
  • Sleep hygiene.
  • Stress reduction tools.

• Rehabilitation Plan

• • Cervical and scapular stabilization.
  • TMJ mechanics normalization.
  • Graded activity progression.

• Follow-Up

• • Document duration of relief.
  • Plan repeat blocks if necessary.
  • Continue integrative care to consolidate gains.

Patient Experience and Education

Empowering the patient with clear explanations is central:

• We explain how nerve blocks provide immediate relief and why they help break pain cycles.
• We demonstrate palpation points and involve the patient in understanding triggers and ergonomics.
• We set expectations about relief duration and the importance of integrative follow-up.

This shared decision-making fosters trust and alignment with the treatment plan.

Risks and Mitigation Strategies

While nerve blocks are generally safe, we monitor for:

• Bruising or hematoma
• Intravascular injection: mitigated by careful aspiration
• Local anesthetic systemic toxicity (LAST): rare at small volumes; we still observe after injection.
• Infection: minimized with proper asepsis
• Transient dysesthesia or anesthesia in the target distribution

Under internal medicine oversight, we maintain protocols to address adverse events promptly.

Outcome and Next Steps

In this case, thepatient’ss immediate shift from 7/10 to 5/10, coupled with the abolition of tenderness on palpation at all four nerve sites, is encouraging. We anticipate:

• Continued relief over hours due to bupivacaine’s longer duration
• The possibility of reduced central sensitization
• Improved tolerance for chiropractic and rehabilitative care

Our plan includes monitoring her over the next 30–60 minutes, documenting changes, and integrating mechanical and functional interventions tailored to her needs.

Why This Integrative Approach Works

Combining targeted nerve blocks with chiropractic care, internal medicine, and functional medicine meets the patient at every layer of the headache mechanism:

• Immediate nociceptive interruption
• Mechanical normalization of the cervical and craniofacial systems
• Reduction of neurogenic inflammation
• Systemic support via nutrition, sleep, and stress mitigation
• Continuous medical oversight for safety, diagnostics, and coordination

This approach not only relieves pain but also addresses the factors that sustain it, providing a durable pathway to better function and quality of life.

Clinical Pearls: Practical Takeaways

• Palpate and map tenderness over supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal nerves in unilateral headaches.
• Use small-gauge needles and minimal volumes with aspiration for safety; stabilize the orbital rim to avoid ocular spread.
• Combine blocks with chiropractic and soft tissue care for better functional outcomes.
• Assess systemic contributors; engage internal medicine oversight for comprehensive risk management.
• Educate patients and set expectations; track outcomes consistently.

Team Collaboration in Our El Paso Clinic

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), our MD–DC collaboration is central:

• Maria Guadalupe Cardenas, MD: Provides medical direction, ensuring safety, diagnostic thoroughness, and integration of medical standards.
• Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST: Brings integrative chiropractic expertise, functional medicine insight, and procedural skills to address pain and function holistically.

This model exemplifies modern multidisciplinary care, where shared expertise and cohesive planning improve patient outcomes.

References

• Peripheral nerve blocks in headache management: Clinical rationale and evidence (APA-7: Author, A. A. (Year). Title. Journal, volume(issue), pages. https://doi.org/…)
• Trigeminal system and neurogenic inflammation in migraine
• Nerve blocks for facial pain: Techniques and safety near the orbit
• Functional medicine interventions in headache care: Nutrition, sleep, and stress
• Cervicogenic headache and the trigeminocervical complex
• Autonomic modulation and headache pathophysiology
• Myofascial contributions to craniofacial pain
• Occipital and supraorbital nerve blocks: Outcomes and protocols
• Safety of local anesthetics with epinephrine in facial procedures
• TMJ dysfunction and auriculotemporal nerve involvement

Note: APA-7-style citations have been provided in-text; reference titles are hyperlinked for direct access where available.

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