Refractory cases may respond to rhizotomy with alcohol (providing an average of 8.5 months of relief 1)) or with radiofrequency ablation.
Persistent cases may require exploration and decompression of the nerve by lysing bands overlying the supraorbital notch, 2) or, ultimately, to neurectomy which provides an average of 33.2 months of relief 3).
Gabapentin (800–2400 mg/d) or pregabalin (150 mg/d) is helpful for some 4).
Topical capsaicin applied to the symptomatic area may help.
(e.g., with alcohol or radiofrequency).
For neurectomy, these nerves are exposed through a 2 cm skin incision parallel to and just above the medial portion of the eyebrow (never through the eyebrow as this can create an unsightly “bi-brow”; shaving the eyebrow is also discouraged since it occasionally does not grow back). The incision is carried down to the bone and the periosteum is elevated caudally towards the supraorbital foramen or notch. The nerves will be visible on the undersurface of the periosteal flap. The supraorbital nerve is freed in its foramen/notch and is then avulsed by grasping it with a mosquito hemostat and twisting the clamp. The nerve avulses “like pulling a worm out of a hole.” The distal portion of the nerve should be located at the site where the periosteum was incised and it, too, should be avulsed. The process can be repeated for the more medially situated supratrochlear nerve.