Nerve Block Management Effectiveness in Hemicrania Continua

Discover strategies for managing headaches with nerve block treatments for better pain relief in the hemicrania continua.

Abstract

Welcome to our in-depth exploration of hemicrania continua, a persistent and often debilitating unilateral headache disorder. In this educational post, I will guide you through the complexities of this condition from my perspective as a clinician practicing at the intersection of chiropractic, functional medicine, and advanced practice nursing. We will begin by understanding the diagnostic criteria and clinical presentation of hemicrania continua, differentiating it from other primary headache disorders like migraines and cluster headaches. We will then delve into the anatomy and physiology of the cranial nerves involved, specifically the trigeminal nerve and its branches—the supratrochlear, supraorbital, zygomaticotemporal, and auriculotemporal nerves—which are often implicated in the pain pathways of this condition. I will share a detailed case study of a 71-year-old patient, demonstrating a diagnostic and therapeutic nerve block procedure step by step. This includes the rationale for the choice of anesthetics, the precise injection technique, and the immediate clinical outcomes. We will also explore the broader context of our integrative care model at Injury Medical Clinic. I will explain how my work as a Doctor of Chiropractic and Family Nurse Practitioner is complemented by the medical directorship of Dr. Maria Guadalupe Cardenas, MD, an internist with over 40 years of experience. Together, we provide a multidisciplinary framework that combines medical oversight with chiropractic adjustments, functional medicine, rehabilitation, and advanced non-invasive therapies to offer a comprehensive, personalized treatment journey for patients with chronic pain and complex neurological conditions.

Introduction: A Journey Into a Unique Headache Disorder

Hello, I’m Dr. Alex Jimenez. Throughout my career across chiropractic, advanced practice nursing, and functional medicine, my primary mission has been to unravel the complexities of chronic pain and offer my patients a path to lasting relief. At Injury Medical Clinic in El Paso, Texas, we have cultivated a unique environment where different medical disciplines converge to create a truly integrative,patient-centered experience.
A cornerstone of our practice is our collaborative structure. I am privileged to work alongside Dr. Maria Guadalupe Cardenas, MD, a highly respected, board-certified internist who serves as our Medical Director and Collaborative Physician. With her extensive four-decade-long experience, Dr. Cardenas provides the essential medical oversight that allows us to safely and effectively integrate a wide range of therapies. Our clinic is a multidisciplinary hub where chiropractic care, medical management, functional medicine, personal injury rehabilitation, and nutritional science are not just co-located but are woven together into a cohesive treatment strategy. This lets us see a patient not just as a diagnosis, but as a whole person with a unique physiology, lifestyle, and history.
Today, I want to guide you through a fascinating and often misdiagnosed condition known as hemicrania continua. This isn’t just another headache. It’s a relentless, one-sided pain that can erode a person’s quality of life. I will share insights from leading researchers and evidence-based practices, and I’ll walk you through a clinical encounter from September 1, 2026, to illustrate how we approach these complex cases. This journey will not only shed light on the condition itself but also demonstrate the power of an integrative approach in modern healthcare.

Understanding Hemicrania Continua: More Than Just a Headache

When patients hear the term “chronic headache”, they often think of migraines. While migraines are certainly prevalent, the world of primary headache disorders is vast and includes conditions like hemicrania continua (HC), which requires a more specific diagnostic lens.
Hemicrania continua, a member of the trigeminal autonomic cephalalgias (TACs), is defined by three core features according to the International Classification of Headache Disorders, 3rd edition (ICHD-3) (Headache Classification Committee of the International Headache Society (IHS), 2018):
Unilateral Pain: The headache is strictly confined to one side of the head and does not switch sides.
Continuous Pain: The pain is present daily and continuously, without any pain-free periods. While the intensity can fluctuate, a baseline level of discomfort remains.
Absolute Response to Indomethacin: The headache is exquisitely and completely responsive to therapeutic doses of the non-steroidal anti-inflammatory drug (NSAID) indomethacin. This response is so characteristic that it is a required diagnostic criterion.
Patients with HC often experience superimposed attacks of more severe pain, during which they may also develop cranial autonomic symptoms on the same side as the headache. These can include:
Conjunctival injection (red eye)
Lacrimation (tearing)
Nasal congestion or rhinorrhea (runny nose)
Eyelid edema (swelling)
Forehead or facial sweating
Miosis (constriction of the pupil) or ptosis (drooping of the eyelid)
The underlying pathophysiology of HC is believed to involve the trigeminovascular system. This complex network involves the trigeminal nerve (the fifth cranial nerve), the primary sensory nerve of the face and head, and the blood vessels of the cranium. Activation of this system releases neuropeptides like calcitonin gene-related peptide (CGRP), which causes vasodilation and neurogenic inflammation and ultimately results in pain (Goadsby et al., 2017). The central mechanisms, particularly the involvement of the posterior hypothalamus, are also an area of active research and help explain the continuous nature of the pain and its autonomic features.

A Clinical Encounter: The Case of a 71-Year-Old with Right-Sided Headache

To bring these concepts to life, let me walk you through a case I managed on the morning of September 1, 2026. A 71-year-old woman presented to our clinic with a long-standing history of a right-sided headache that fit the clinical picture of hemicrania continua. She described a constant, dull ache on the right side of her head, punctuated by episodes of sharper, more intense pain. Before our procedure, she rated her current pain as a seven out of ten on a standard pain scale.
My immediate goal was twofold: first, to confirm the peripheral nerve involvement contributing to her pain pattern, and second, to provide immediate, albeit temporary, therapeutic relief. A successful diagnostic nerve block can provide profound insight into the patient’s specific pain generators.

The Diagnostic Examination: Pinpointing the Pain

Before any intervention, a thorough physical examination is paramount. For this patient, I focused on palpating the terminal branches of the trigeminal nerve, which are common sites of peripheral sensitization and pain in various headache disorders. Using gentle but firm pressure, I assessed for allodynia (pain from a stimulus that does not normally provoke pain) and hyperalgesia (an increased response to a painful stimulus).
I identified four specific points of exquisite tenderness, which corresponded directly to the anatomical locations of four key sensory nerves:
Supratrochlear Nerve: Located just medial to the supraorbital notch, this nerve provides sensation to the medial forehead and upper eyelid. When I applied pressure here, the patient immediately confirmed, “Yes,” it was painful.
Supraorbital Nerve: Found at the supraorbital notch or foramen, along the upper rim of the orbit. This larger nerve supplies most of the forehead and scalp. Palpation here also elicited a clear “Yes, yes” response of pain.
Zygomaticotemporal Nerve: This smaller branch emerges through a foramen in the zygomatic (cheek) bone to supply the skin over the temporal fossa (the “temple”). When I pressed on this area, she again confirmed, “Right there. Yes.”
Auriculotemporal Nerve: This nerve travels in front of the ear, ascending over the zygomatic arch to supply the skin of the temporal region and parts of the ear. Palpation here confirmed localized tenderness.
The patient’s clear and reproducible pain response at these four locations strongly suggested that these peripheral branches of the trigeminal nerve were significant contributors to her overall headache experience. This phenomenon, known as peripheral sensitization, occurs when the nerve endings become hyperexcitable, lowering the threshold for firing and amplifying pain signals sent to the brain. I hypothesized that temporarily silencing these nerves could interrupt the barrage of pain signals and provide relief.

Preparing for the Nerve Block: A Meticulous Approach

With the target nerves identified, the next step was to prepare for the peripheral nerve block procedure. Precision, safety, and patient comfort guide this step.
Marking the Injection Sites: I used the retracted, smooth tip of a ballpoint pen to make very light ink marks at the four tender points. It’s crucial not to apply too much pressure, as this can cause discomfort and tissue indentation, making accurate needle placement more difficult.
Aseptic Technique: The skin was then meticulously prepped with Betadine (povidone-iodine), an antiseptic that reduces the microbial load on the skin and minimizes infection risk. We allowed it to air-dry to ensure its full antimicrobial effect.
The Anesthetic Cocktail: For the injection itself, I prepared a specific mixture designed to provide both rapid onset and extended duration of action. The solution consisted of:
0.5% Lidocaine with Epinephrine: Lidocaine is a fast-acting local anesthetic that typically begins working within minutes. Adding epinephrine, a vasoconstrictor, serves two purposes: it reduces local bleeding and, more importantly, slows systemic absorption of lidocaine, prolonging its local effect and reducing potential toxicity (Becker & Reed, 2012).
0.5% Bupivacaine: Bupivacaine has a much slower onset of action but a significantly longer duration, often providing pain relief for several hours.
By combining these two agents, we create a synergistic effect: lidocaine provides immediate relief and comfort, while bupivacaine takes over to provide a longer therapeutic window. The goal is not just to numb the area for a few minutes but to break the pain cycle for an extended period. I drew up a total of 1 mL of this mixture for each of the four injection sites.

The Procedure: A Step-by-Step Execution of the Nerve Blocks

Performing injections on the face, especially near the eyes, requires extreme care and a gentle hand. The patient was understandably apprehensive, so clear communication and a calm demeanor were essential.
Choice of Needle: I selected a 30-gauge, half-inch needle. This ultra-fine needle minimizes tissue trauma and patient discomfort. While a topical anesthetic spray can be used in other areas, its use so close to the eyes is contraindicated. In this case, the small needle size makes the initial injection itself less uncomfortable than the spray would be.
Injection Technique for Supratrochlear and Supraorbital Nerves:
For the first two injections targeting the nerves along the brow ridge, safety is the number one priority. To prevent the anesthetic from diffusing inferiorly into the orbit (the eye socket), I placed my non-dominant thumb firmly against the patient’s orbital rim, just below the injection site. This creates a physical barrier, or a bolster, to direct the fluid superiorly into the subcutaneous tissue of the forehead.
I gently advanced the needle to the marked supratrochlear nerve site until I felt the delicate “tap” of the needle tip against the periosteum (the outer surface of the bone).
I then withdrew the needle slightly, about 1-2 millimeters, so the tip was in the subcutaneous space just above the bone where the nerve lies.
Aspiration is a critical safety step. Before injecting, I pulled back on the plunger to ensure the needle was not inside a blood vessel. The absence of a blood return in the syringe hub (“no blood”) confirms a safe position.
I slowly and steadily injected 1 mL of the anesthetic solution. During the injection, I felt the fluid pressure building against my thumb, confirming that my bolster was effectively preventing orbital diffusion.
I repeated this exact process for the supraorbital nerve, again maintaining the protective thumb placement. The patient tolerated these first two injections well, with minimal discomfort.
Injection Technique for Zygomaticotemporal and Auriculotemporal Nerves:
For the zygomaticotemporal nerve on the cheekbone, the technique was similar. I advanced the needle to touch bone, withdrew slightly, and aspirated. This area is less critical for orbital diffusion, so the thumb bolster was not necessary.
For the final injection targeting the auriculotemporal nerve in the temporal region, an extra layer of caution is required. The superficial temporal artery runs in proximity to this nerve. Therefore, aspiration is absolutely mandatory here to avoid an inadvertent intravascular injection, which could lead to systemic toxicity. After confirming I was not in the artery, I proceeded to inject the final 1 mL of anesthetic.
The entire procedure, from marking to the final injection, took only a few minutes. I maintained communication with the patient throughout, reassuring her and monitoring her comfort.

Immediate Post-Procedure Assessment: Gauging the Efficacy

The true test of a nerve block’s success is the patient’s subjective response. Immediately after completing the injections, I began the assessment.
“Was that painful?” I asked.
“No, no. It felt pretty good,” she replied, visibly relieved. “It was a little pinch on a couple of them. Not as bad as we feared.”
This immediate feedback is valuable, but the primary endpoint is the effect on her headache. I asked her to re-evaluate her pain:
“You reported your headache was a seven out of ten just a moment ago. What number would you assign your headache right now?”
“I think it’s better,” she said thoughtfully. “More like a five.“
A two-point drop on the pain scale within minutes of the procedure is a very encouraging sign. It indicates that peripheral nerve sensitization was a major component of her pain and that the anesthetic was working as intended.
Next, I performed a follow-up palpation exam:
I pressed over the supratrochlear nerve site. “Does that hurt?” I asked. “No,” she said. “Did it hurt before?” “Yes. Yes, it did.“
I moved to the supraorbital nerve. “Does it hurt when I press over here?” “No.”
I then palpated the zygomaticotemporal and auriculotemporal nerves, both of which were no longer tender.
The resolution of localized tenderness (allodynia), combined with the reduction in her baseline headache intensity, provided a clear, positive diagnostic result. It confirmed that these four nerves were actively involved in her hemicrania continua pain pathway.
The immediate goal was achieved, but the long-term hope is that this intervention can do more. By silencing the hyperexcitable nerves for several hours, we aim to break the pain cycle. This period of relief can allow the central nervous system to “calm down,” a process known as down-regulating central sensitization. For some patients, a single series of blocks can provide relief that far outlasts the anesthetic’s pharmacological effect, sometimes for days or even weeks. For this patient, we would monitor her progress over the next hour and the following days to see whether the headache breaks completely.

The Integrative Chiropractic and Medical Framework: Our Comprehensive Approach

The nerve block procedure I’ve just described is a powerful tool, but it’s only one piece of a much larger puzzle. At Injury Medical Clinic, we believe that sustainable healing from chronic conditions like hemicrania continua requires a multifaceted approach that addresses the body as an interconnected system. This is where our unique integrative model, guided by Dr. Cardenas and me, truly shines.
Our philosophy is built on the understanding that pain, especially chronic neurological pain, is rarely caused by a single, isolated issue. It’s often the result of a cascade of dysfunction involving the musculoskeletal system, the nervous system, metabolic health, and even psychosocial factors.

The Role of Chiropractic Care in Headache Management

As a Doctor of Chiropractic, my primary focus is on the biomechanical and neurological integrity of the spine, particularly the cervical spine (the neck). The upper cervical spine houses critical neurological structures, including the brainstem and the upper cervical nerve roots, which have intricate connections with the trigeminal nucleus in the brainstem. This anatomical relationship is known as the trigeminocervical complex (Bogduk, 2003).
Cervicogenic Inputs: Misalignments or dysfunctional movement in the joints of the upper neck (vertebral subluxations) can create noxious mechanical and inflammatory signals. These signals travel from the cervical nerve roots (C1, C2, C3) and converge on the trigeminocervical nucleus, which receives sensory information from the trigeminal nerve. The brain can misinterpret these cervical signals as originating from the head, a phenomenon known as referred pain. This can initiate or exacerbate a headache.
Chiropractic Adjustments: Gentle, specific chiropractic adjustments are designed to restore proper motion and alignment to the cervical vertebrae. By correcting these biomechanical faults, we can:
Reduce nerve irritation: Alleviate direct or indirect pressure on the cervical nerve roots and surrounding tissues.
Improve proprioception: Restore the normal flow of sensory information from the joints and muscles of the neck to the brain, which can help down-regulate pain processing centers.
Decrease muscle tension: Hypertonicity in the suboccipital and other neck muscles is a common finding in headache sufferers. Adjustments can help normalize muscle tone by resetting the neural feedback loops that control muscle contraction.
For a patient with hemicrania continua, chiropractic care is not aimed at “curing” the primary headache disorder itself. Instead, it serves to remove any co-existing cervicogenic contributions that may be lowering the threshold for an attack or adding to the overall pain burden. By optimizing cervical spine function, we can reduce the overall “noise” in the trigeminocervical complex, potentially making the primary headache less frequent, less severe, and more responsive to other treatments.

Functional Medicine: Looking for the Root Cause

Functional medicine provides another critical layer to our integrative approach. Instead of just managing symptoms, we ask why the patient is experiencing this dysfunction in the first place. For headache disorders, we investigate several key areas:
Nutrient Deficiencies: Certain micronutrients are essential for proper neurological function and inflammation control. Deficiencies in magnesium, Coenzyme Q10 (CoQ10), and riboflavin (Vitamin B2) have been linked to an increased risk of headaches, particularly migraines (Schürks et al., 2008; Sándor et al., 2005). We use advanced laboratory testing to identify and correct these deficiencies with targeted supplementation.
Gut Health and Food Sensitivities: The gut-brain axis is a bidirectional communication highway between the gastrointestinal system and the central nervous system. An imbalanced gut microbiome (dysbiosis) or increased intestinal permeability (“leaky gut”) can trigger systemic inflammation, which can, in turn, lower the threshold for headache attacks. Identifying and eliminating trigger foods through an elimination diet or food sensitivity testing can be a game-changer for many patients.
Hormonal Imbalances: Fluctuations in hormones, especially estrogen in women, can be a powerful headache trigger. We assess sex hormones and adrenal function (e.g., cortisol levels) to identify imbalances that may be contributing to the patient’s condition.
Mitochondrial Dysfunction: Mitochondria are the powerhouses of our cells, including our neurons. When they don’t function optimally, they can trigger an “energy crisis” in the brain, making it more susceptible to conditions like headaches and neuroinflammation. Supporting mitochondrial health with nutrients like CoQ10, L-carnitine, and D-ribose can be a foundational part of our treatment plan (Yorns & Hardison, 2013).
By addressing these underlying metabolic and physiological imbalances, functional medicine helps to improve the body’s overall resilience and reduce the systemic factors that may be perpetuating the headache cycle.

The Synergy of a Multidisciplinary Team

The true strength of our clinic lies in how these different disciplines are woven together under the expert medical oversight of Dr. Maria Cardenas. Her role as our Medical Director is indispensable.
Medical Diagnosis and Oversight: Dr. Cardenas provides the definitive medical diagnosis and ensures that all potential red flags or more serious underlying pathologies are ruled out. Her internal medicine expertise is crucial for managing patients with complex comorbidities.
Pharmacological Management: For a condition like hemicrania continua, the response to indomethacin is diagnostic. Dr. Cardenas manages the prescription and monitoring of such medications, ensuring they are used safely and effectively, especially considering the potential side effects of long-term NSAID use.
Collaborative Treatment Planning: We hold regular team meetings to discuss patient cases. I might present my findings from a chiropractic and functional neurology perspective, while Dr. Cardenas provides her medical insights. Together, we formulate a comprehensive treatment plan. For the patient described earlier, the plan might look like this:
Immediate Pain Control: Peripheral nerve blocks performed by me (as an FNP) under Dr. Cardenas’s collaborative agreement to break the acute pain cycle.
Biomechanical Support: A course of gentle chiropractic adjustments to address underlying cervicogenic factors.
Medical Management: A trial of indomethacin prescribed and monitored by Dr. Cardenas to confirm the diagnosis and provide baseline control.
Functional Medicine Investigation: Lab testing for nutritional deficiencies, food sensitivities, and hormonal imbalances to address root-cause contributors.
Rehabilitation: Our team of rehabilitation specialists would design a program of specific exercises to improve neck posture, strengthen deep neck flexors, and provide lasting stability.
This integrated model ensures the patient receives the best of all worlds in a coordinated, synergistic way. We are not just a collection of individual practitioners; we are a cohesive team working toward a single goal: the patient’s well-being.

Conclusion: A New Horizon for Headache Sufferers

The case of the 71-year-old patient with hemicrania continua is a powerful illustration of how a precise diagnostic procedure can provide immediate clarity and relief. The successful nerve block not only alleviated her pain but also confirmed the involvement of specific peripheral nerves, guiding our subsequent treatment strategy.
However, the larger takeaway is the power of the integrative framework in which this procedure took place. Managing complex chronic pain requires moving beyond a single-modality approach. It demands a holistic perspective that honors the intricate connections between the body’s systems—musculoskeletal, neurological, metabolic, and biochemical.
At Injury Medical Clinic, our collaboration across chiropractic care, advanced practice nursing, functional medicine, and internal medicine, under the leadership of Dr. Maria Cardenas, allows us to provide this level of comprehensive care. We strive not only to manage symptoms but to restore function, improve resilience, and empower our patients to reclaim their lives from chronic pain. If you or a loved one is struggling with a persistent headache, know that there is hope. By looking at the whole picture, we can uncover new possibilities for healing and well-being.

References

• Becker, D. E., & Reed, K. L. (2012). Local anesthetics: Review of pharmacological considerations. Anesthesia Progress, 59(2), 90–102. https://doi.org/10.2345/0003-3006-59.2.90
• Bogduk, N. (2003). The anatomy and pathophysiology of neck pain. Physical Medicine and Rehabilitation Clinics of North America, 14(3), 455–472. https://doi.org/10.1016/s1047-9651(03)00033-6
• 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
• Headache Classification Committee of the International Headache Society (IHS). (2018). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38(1), 1–211. https://doi.org/10.1177/0333102417738202
• Sándor, P. S., Di Clemente, L., Coppola, G., Saenger, U., Fumal, A., De Pasqua, V., Seidel, L., & Schoenen, J. (2005). Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology, 64(4), 713–715. https://doi.org/10.1212/01.WNL.0000151975.03598.ED
• Schürks, M., Diener, H.-C., & Goadsby, P. J. (2008). Update on the prophylaxis of migraine. Current Treatment Options in Neurology, 10(1), 20–29. https://doi.org/10.1007/s11940-008-0004-9
• Yorns, W. R., & Hardison, H. H. (2013). Mitochondrial dysfunction in migraine. Seminars in Pediatric Neurology, 20(3), 188–193. https://doi.org/10.1016/j.spen.2013.08.004

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