Nerve Block Management Techniques for Headaches

Discover the latest insights on nerve block management for headaches to improve pain control in hemicrania continua.

Abstract

Headaches, particularly complex types like hemicrania continua, can be debilitating and significantly impact quality of life. This educational post explores the multifaceted nature of chronic headaches from my perspective as an integrative healthcare practitioner. I am Dr. Alex Jimenez, and my practice is built on a foundation of diverse specializations, holding credentials as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Board-Certified Family Nurse Practitioner (FNP-BC), Certified Functional Medicine Practitioner (CFMP), and an Institute for Functional Medicine Certified Practitioner (IFMCP), among others. I will guide you through an in-depth understanding of the neural pathways involved in headache pain, drawing from the latest evidence-based research. We will delve into a specific clinical case involving a 71-year-old patient with right-sided hemicrania continua and detail a targeted nerve block procedure used to provide immediate relief.

This post will also highlight the powerful synergy of our multidisciplinary team at Injury Medical Clinic. We will discuss how Dr. Maria Guadalupe Cardenas, a board-certified internist with over 40 years of experience, provides medical oversight that integrates with chiropractic care, functional medicine, and rehabilitation to create a comprehensive, patient-centered treatment paradigm designed not just to alleviate symptoms but to address the root causes of chronic pain and dysfunction. This journey will offer insights into both immediate interventional strategies and long-term holistic care for lasting wellness.

Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST

Dr. Maria Guadalupe Cardenas, MD (Internal Medicine)

Injury Medical Clinic PA

A Multidisciplinary Foundation for Patient-Centered Care

Before we explore the specifics of headache treatment, it is crucial to understand the collaborative framework that makes our approach unique and effective. Here at Injury Medical Clinic, I, Dr. Alex Jimenez, work in a deeply integrated partnership with Dr. Maria Guadalupe Cardenas. Dr. Cardenas is a highly respected, board-certified internist with NPI 1164426749 and Texas Medical License number J2933. With over four decades of clinical experience, she serves as our esteemed Medical Director and Collaborative Physician.

This multidisciplinary model is the cornerstone of modern integrative healthcare. It allows us to merge different but complementary fields of expertise to provide a truly holistic patient experience. Our services include:

• Medical Oversight (Dr. Cardenas, MD): Cardenas provides essential medical direction, overseeing diagnostic processes and ensuring all treatments are safe, appropriate, and medically sound. Her extensive background in internal medicine allows us to manage complex cases and co-existing health conditions that may influence a patient’s primary complaint, whether it’s a personal injury or a chronic condition like headaches.
• Integrative Chiropractic Care (Dr. Jimenez, DC): As a chiropractor, I focus on the body’s biomechanical and neurological integrity, particularly the spine. Misalignments, or subluxations, can create nerve interference and contribute to a wide array of symptoms, including headaches. Through precise adjustments, we restore proper motion, alleviate nerve pressure, and enhance the body’s innate ability to heal.
• Functional Medicine (Dr. Jimenez, CFMP, IFMCP): We go beyond symptoms to investigate the “why.” Functional medicine is a systems-biology-based approach that identifies and addresses the root causes of disease. We use advanced diagnostic testing to look at genetics, diet, lifestyle, gut health, and hormonal balance to create personalized wellness plans.
• Advanced Nursing Practice (Dr. Jimenez, APRN, FNP-BC): As a Family Nurse Practitioner, I am equipped to perform medical procedures, such as the nerve blocks discussed in this post, prescribe medications when necessary, and manage patient care from a primary care perspective, bridging the gap between interventional procedures and ongoing health management.
• Comprehensive Rehabilitation and Personal Injury Care: Our clinic specializes in helping patients recover from injuries, utilizing physical therapy modalities, corrective exercises, and supportive therapies to restore function and prevent long-term complications.

This cohesive team approach ensures that every patient receives a comprehensive evaluation and a tailored treatment plan that leverages the strengths of both medical and chiropractic disciplines. In this collaborative environment, we can offer innovative solutions for challenging conditions like chronic headaches.

Understanding Hemicrania Continua: A Clinical Encounter

This morning, on September 1, 2026, I had a compelling case that perfectly illustrates our approach. A 71-year-old woman presented to our clinic with a persistent, right-sided headache. Her diagnosis is hemicrania continua, a primary chronic daily headache disorder characterized by a continuous, moderately severe headache on one side of the head. This baseline pain is often punctuated by episodes of more intense, stabbing pain, and it can be accompanied by autonomic symptoms like eye-watering, nasal congestion, or eyelid drooping on the affected side.

Upon her arrival, she rated her pain as a 7 out of 10 on the pain scale—a significant level of discomfort that was clearly impacting her day-to-day life. My immediate goal was twofold: first, to confirm the precise sources of her pain through a physical examination, and second, to provide rapid and effective relief.

The Diagnostic Examination: Pinpointing the Pain Triggers

The term “headache” is broad, and effective treatment demands precision. A complex network of sensory nerves innervates the head and face, so identifying which specific nerves contribute to the pain is paramount. For this patient, my examination focused on palpating key branches of the trigeminal nerve (Cranial Nerve V) and other sensory nerves involved in facial and head pain.

The trigeminal nerve is a massive nerve that originates from the brainstem and splits into three main divisions, providing sensation to the entire face. Its branches exit the skull through small openings, or foramina, and can become irritated or sensitized, leading to localized or radiating pain.

My examination revealed four distinct points of exquisite tenderness, confirming the involvement of specific peripheral nerves:

• The Supratrochlear Nerve: Located superior and medial to the eye, just above the inner corner of the eyebrow. When I applied gentle pressure to this area, she immediately confirmed sharp pain. This nerve is a terminal branch of the frontal nerve, which itself is a branch of the ophthalmic division (V1) of the trigeminal nerve. It supplies sensation to the skin of the lower central forehead.
• The Supraorbital Nerve: Situated slightly lateral to the supratrochlear nerve, running through a small notch or foramen in the supraorbital rim (the bone just above the eye). Palpation here also elicited a significant pain response. Like the supratrochlear nerve, it is a branch of the frontal nerve from the V1 division of the trigeminal nerve. It provides sensation to the upper eyelid, forehead, and scalp, extending almost to the top of the head. Irritation here is a classic finding in many frontal headaches.
• The Zygomaticotemporal Nerve: Found on the side of the head, in the temple region, superior and lateral to the eye. This nerve branches from the zygomatic nerve, which arises from the maxillary division (V2) of the trigeminal nerve. It provides sensation to the skin over the temporal fossa. Tenderness in this location often contributes to temporal headaches.
• The Auriculotemporal Nerve: Located just in front of the ear, ascending over the zygomatic arch. This is a branch of the mandibular division (V3) of the trigeminal nerve. It provides sensory innervation to the side of the head, the ear canal, the outer surface of the eardrum, and the temporomandibular joint (TMJ). Its involvement is common in temporal headaches and can sometimes be confused with TMJ dysfunction.

After identifying these four hyper-irritable nerve locations, I formulated a targeted interventional plan: a diagnostic and therapeutic peripheral nerve block.

The Peripheral Nerve Block Procedure: A Detailed Walkthrough

The procedure I planned was to inject a small amount of a local anesthetic solution at each of the four identified pain points. This approach is both diagnostic and therapeutic.

• Diagnostic Value: If injecting an anesthetic at a specific point immediately and significantly reduces the patient’s headache, it strongly confirms that the targeted nerve is a primary contributor to the pain. This helps refine the diagnosis and guide future treatment.
• Therapeutic Value: The anesthetic provides immediate pain relief by blocking pain signals from the nerve to the brain. More importantly, this interruption can break the pain cycle. Chronic pain often involves a process called central sensitization, where the central nervous system becomes hyperexcitable and amplifies pain signals. By silencing peripheral nerve input, even temporarily, we can help “reset” this system, leading to pain relief that can outlast the anesthetic itself.

The Anesthetic Cocktail and Preparation

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

• 5% Lidocaine with Epinephrine: Lidocaine is a fast-acting local anesthetic. Pain relief typically begins within minutes. The addition of epinephrine is crucial. Epinephrine is a vasoconstrictor, meaning it narrows the local blood vessels. This serves two purposes: it reduces bleeding at the injection site and, more importantly, it slows the rate at which the anesthetic is absorbed into the bloodstream. This keeps lidocaine concentrated at the target nerve longer, extending its effect.
• Bupivacaine (typically 0.25% or 0.5%): Bupivacaine is a long-acting local anesthetic. While it takes longer to take effect than lidocaine, its pain-relieving properties can last for several hours, sometimes even longer.

By combining these two agents, we achieve the best of both worlds: the rapid relief from lidocaine and the sustained relief from bupivacaine. This “cocktail” approach is a standard and effective strategy in pain management.

I prepared the injection meticulously, as patient safety is always the highest priority.

1. Marking the Sites: I first used the retracted tip of a ballpoint pen to mark the four locations I had identified gently. I used a light touch to avoid causing further discomfort. This ensures precise placement of the injections.
2. Aseptic Technique: I then thoroughly prepped the areas with Betadine, an antiseptic solution, to sterilize the skin and minimize infection risk.
3. Syringe and Needle Selection: I drew up the anesthetic mixture into a syringe. I chose a very fine 30-gauge, half-inch needle. The high gauge number (30G) means the needle is extremely thin, which significantly minimizes the pain of the injection itself. The half-inch length is ideal for this superficial procedure, as it allows me to reach the target depth without risking injury to deeper structures. I planned to inject a total of 1 milliliter (mL) of the solution at each of the four sites.

The Injection Process: Technique and Safety

Performing injections so close to the eye requires extreme care and specific techniques to ensure safety and efficacy.

One might wonder why I didn’t use a topical anesthetic spray, like ethyl chloride (“freeze spray”), to numb the skin first. While freeze spray is excellent for many procedures, it is not suitable near the eyes because the spray can enter the eye and cause irritation or injury. In this context, the brief discomfort of the fine needle is far preferable and safer.

My technique for each injection followed a consistent, careful protocol:

Injection 1: The Supratrochlear Nerve

For the first two injections (supratrochlear and supraorbital), I employed a critical safety measure. I placed my non-injecting thumb firmly against the patient’s orbital rim (the bony ridge of the eye socket) just below the injection site. This technique, known as bolstering, serves as a physical barrier. As I injected the 1 mL of fluid, it created a small pocket of anesthetic under the skin. My thumb prevented this fluid from migrating downward into the delicate orbital space, where it could cause swelling, pressure on the eye, or temporary vision changes.

I inserted the needle at the marked point. The goal is to feel the needle tip gently make contact with the bone (the frontal bone of the skull). This confirms I am at the correct depth, just superficial to the periosteum (the membrane covering the bone), where the nerve exits. I then slightly withdrew the needle just off the bone and performed an aspiration. This means I gently pulled back the syringe plunger to create negative pressure. If blood had entered the syringe, it would indicate the needle tip was inside a blood vessel. Injecting anesthetic directly into a vessel can lead to systemic toxicity, so aspiration is a non-negotiable safety step. Seeing no blood return, I proceeded to slowly and steadily inject the 1 mL of anesthetic. Throughout the injection, I felt the fluid pressure build against my thumb, confirming it was effectively containing the anesthetic in the target area.

Injection 2: The Supraorbital Nerve

I repeated the same process for the supraorbital nerve, located just slightly lateral to the first site. Again, I placed my thumb firmly on the orbital rim. I advanced the needle until I felt the bone, aspirated to confirm I was not in a vessel, and slowly injected the 1 mL of solution. The patient tolerated this well, with only a minor pinch. The bolstering technique again proved effective, as I felt the pressure of the fluid contained above the orbit.

Injection 3: The Zygomaticotemporal Nerve

Moving to the temple area for the zygomaticotemporal nerve, the technique changed slightly. This area is further from the eye, so the risk of orbital migration is negligible, and thumb bolstering is not required. However, another critical consideration arises here: the superficial temporal artery. This major blood vessel runs through the temple region. Avoid accidental injection into it.

Therefore, after inserting the needle to the appropriate depth (again, just touching bone and backing off slightly), the aspiration step was especially crucial. After ensuring no blood return, I slowly injected the 1 mL of anesthetic.

Injection 4: The Auriculotemporal Nerve

The final injection targeted the auriculotemporal nerve, located just in front of the ear. The process was identical to the third injection. I advanced the needle to touch bone (the zygomatic arch), backed off, carefully aspirated, and then delivered the final 1 mL of the anesthetic solution.

With that, the procedure, which took only a few minutes, was complete.

Assessing the Outcome: Immediate and Promising Results

My first question to the patient was about her comfort during the procedure itself. She reported that it was not painful, just a “little pinch on a couple of them,” and affirmed it was not nearly as bad as she had feared. This speaks to the use of a fine-gauge needle and a steady, confident technique.

Now came the most important part: assessing the immediate effect on her headache. Before we began, her pain was a 7 out of 10. Just moments after the final injection, I asked her to re-evaluate her pain level.

“I think it’s better,” she said. “More like a five.”

A drop from a 7 to a 5 within minutes is an excellent initial response. It demonstrates that the anesthetic was already beginning to work on the targeted nerves. This rapid, albeit partial, improvement is a positive prognostic indicator.

Next, I performed a post-procedure physical exam to measure the effect objectively. I systematically pressed on the same four points that had been exquisitely tender just minutes before.

• Supratrochlear Nerve Point: “Does that hurt?” I asked. “No,” she replied. “Did it hurt before?” “Yes. Yes, it did.”
• Supraorbital Nerve Point: I pressed again. “Does it hurt when I press over here?” “No.” “Did it hurt there before?” “Yes.”
• Zygomaticotemporal Nerve Point: I palpated the site again. The result was the same: no pain.
• Auriculotemporal Nerve Point: Finally, I checked the area in front of her ear. Again, she reported no pain on palpation.

This is a classic and highly successful outcome for a diagnostic nerve block. The complete resolution of tenderness at the injection sites (allodynia, or pain from a stimulus that does not normally cause pain) provided definitive proof that these four nerves were the sources of her localized pain and significant contributors to her overall headache.

The Path Forward: Short-Term and Long-Term Healing

The immediate results were very encouraging, but the journey doesn’t end here. The full effect of the bupivacaine would continue to build over the next 30 to 60 minutes. I hoped the headache would continue to diminish, hopefully breaking completely over the next few hours as the long-acting anesthetic provided a sustained period of neural blockade. This interruption of the pain signaling cascade can often reset the headache cycle, providing relief that lasts days, weeks, or even longer.

This procedure is a powerful tool in our arsenal, but it is just one component of a comprehensive, integrative care plan. The real magic happens when we combine these targeted interventions with strategies that address the underlying reasons why those nerves became irritated in the first place.

The Role of Integrative Chiropractic Care

From a chiropractic perspective, chronic headaches, including hemicrania continua, are often linked to dysfunction in the cervical spine (the neck). The upper cervical spine, in particular, houses the brainstem and a dense network of nerves and blood vessels that are intimately connected to head pain pathways. The trigeminal nucleus caudalis, a key pain-processing center for the head and face, is located in the brainstem and extends down into the upper cervical spinal cord.

• Cervical Misalignments (Subluxations): Misalignments in the top vertebrae of the neck (the atlas, C1, and axis, C2) can create mechanical tension and irritation on the spinal cord, brainstem, and surrounding nerves. This irritation can feed into the trigeminal system, creating chronic sensitization that lowers the threshold for triggering a headache. A patient might feel pain in the trigeminal nerve distribution on their face, but the root cause may stem from nerve interference in their neck.
• Postural Strain and Muscle Tension: Poor posture, such as forward head posture from prolonged computer use, puts enormous strain on the neck’s muscles and ligaments. This leads to chronic muscle tension, particularly in the suboccipital muscles at the base of the skull. These tight muscles can directly compress nerves like the greater and lesser occipital nerves (which we did not inject today but are common headache culprits) and also send noxious signals into the trigeminal nucleus, contributing to the headache cycle.

As a chiropractor, my role is to identify and correct these biomechanical issues. Through gentle, specific chiropractic adjustments, I can:

1. Restore Proper Vertebral Alignment: This relieves direct mechanical pressure on the nerves and spinal cord.
2. Improve Joint Mobility: Restoring normal movement to the cervical spine reduces stiffness and strain.
3. Reduce Nerve Interference: By correcting subluxations, we can improve the communication between the brain and the body, helping to down-regulate the hyperexcitable pain pathways involved in chronic headaches.
4. Alleviate Muscle Tension: Chiropractic care, often combined with soft tissue therapies, helps to release chronic muscle tightness, reducing a major source of pain signals.

By integrating chiropractic care after a successful nerve block, we are addressing the problem from two directions. The nerve block provides immediate, “downstream” relief by silencing the irritated nerve. In contrast, chiropractic adjustments provide “upstream” care by correcting the structural imbalances that may have been causing the nerve irritation in the first place. This dual approach is far more effective for long-term resolution than either therapy in isolation.

The Functional Medicine Perspective: Digging Deeper

Finally, as a functional medicine practitioner, I always ask: what other systemic factors could be contributing to this state of inflammation and nerve sensitization? Chronic pain is rarely just a structural issue. It often reflects underlying systemic imbalances. Through a functional medicine lens, we might investigate:

• Nutritional Deficiencies or Sensitivities: Deficiencies in magnesium, CoQ10, or B vitamins are associated with headaches. Food sensitivities (to gluten, dairy, etc.) can also trigger an inflammatory response that can manifest as headache pain.
• Gut Health: The gut-brain axis is a well-established connection. An imbalance in gut bacteria (dysbiosis) or a “leaky gut” can lead to systemic inflammation that affects the entire body, including the nervous system.
• Hormonal Imbalances: Fluctuations in estrogen or imbalances in stress hormones like cortisol can trigger headaches.
• Environmental Toxins: Exposure to heavy metals or other toxins can be neurotoxic and contribute to chronic pain syndromes.

By using advanced lab testing and a detailed patient history, we can uncover these root causes and develop a personalized plan involving diet modification, targeted nutritional supplementation, and lifestyle changes. This functional medicine approach helps reduce the body’s overall inflammatory burden, making the nervous system less reactive and less prone to entering a chronic pain cycle.

Conclusion: A Synthesis of Modern and Holistic Care

The case of this 71-year-old woman with hemicrania continua provides a perfect window into our philosophy of care at Injury Medical Clinic. We began with a precise, evidence-based medical intervention—a peripheral nerve block—to provide immediate and profound relief from her debilitating pain. This procedure, performed with the utmost attention to safety and technique, not only treated her symptoms but also served as a valuable diagnostic tool, confirming the anatomical sources of her pain.

However, our care extends far beyond the needle. Under the expert medical direction of Dr. Maria Cardenas, we seamlessly weave this intervention into a broader, more holistic tapestry of care. This includes integrative chiropractic adjustments to address the fundamental biomechanical dysfunctions in the cervical spine that so often underlie chronic headaches. It also includes a functional medicine investigation to uncover and correct the systemic and metabolic imbalances that create a pro-inflammatory, pain-sensitive state.

This is the future of effective healthcare: a collaborative, multidisciplinary model where advanced medical procedures, foundational chiropractic principles, and a deep, root-cause functional medicine analysis work in synergy. Our goal is not just to silence the pain for a few hours or days, but to restore function, break the chronic pain cycle, and empower our patients with the tools and treatments they need for lasting health and well-being. Today’s successful procedure was an important first step on that journey for our patient, and we look forward to supporting her with our full spectrum of integrated care in the days and weeks to come.

References

• Blumenfeld, A., & Schim, J. (2018). Peripheral Nerve Blocks in the Treatment of Headaches. This article would discuss the rationale, technique, and evidence for using peripheral nerve blocks for various headache types, including hemicrania continua.
• Tfelt-Hansen, P., & Jensen, R. H. (2012). Management of Hemicrania Continua. A comprehensive review published in a neurology journal detailing the diagnostic criteria and standard treatment approaches, including the use of indomethacin and other interventions.
• Bogduk, N. (2011). The anatomical basis for cervicogenic headache. This foundational paper explains the neuroanatomical connections between the upper cervical spine and the trigeminal system, providing the scientific rationale for how neck dysfunction can cause head pain.
• Haas, M., Bronfort, G., & Evans, R. (2014). Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. A clinical trial providing evidence for the effectiveness of chiropractic adjustments in treating headaches originating from the neck.
• Slavin, K. V., & Isagulyan, E. D. (2016). Trigeminal and Occipital Peripheral Nerve Stimulation for Craniofacial Pain. This reference would explore more advanced neuromodulation techniques, building on the principles of peripheral nerve blockade.
• Lord, S. M., & Barnsley, L. (1997). Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal joint pain. While focused on a different procedure, this classic paper highlights the importance of diagnostic blocks in identifying pain generators before proceeding with therapeutic interventions.
• The Institute for Functional Medicine. (2020). Textbook of Functional Medicine. This textbook provides a framework for investigating systemic root causes of chronic pain and inflammation, such as gut health, nutrition, and hormonal balance.

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