A 35-year-old female sustained a fall onto the left parietal region three months ago with no immediate pain; she now has localized pain, tenderness to touch, and numbness of the left side of the face and ear. What is the most likely diagnosis and the recommended treatment regimen with dosages?

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Last updated: September 22, 2026 • View editorial policy

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Diagnosis and Treatment

This patient most likely has a delayed complication from her head trauma—either a chronic subdural hematoma, skull fracture with nerve involvement, or post-traumatic neuropathy—and requires urgent neuroimaging (CT or MRI of the head) before initiating treatment; if imaging is negative, treat as post-traumatic neuropathic pain with nortriptyline 10-25 mg at bedtime, titrating by 10-25 mg weekly to 75-150 mg daily.

Clinical Reasoning

The delayed onset of pain (3 months post-trauma) with new neurological symptoms (facial numbness and ear numbness) in the distribution of cranial nerves suggests either:

  1. Structural complications: Chronic subdural hematoma, skull fracture affecting the temporal bone/petrous ridge, or epidural collection
  2. Neuropathic pain: Post-traumatic nerve injury to branches of the trigeminal nerve (V2/V3) or greater auricular nerve

The parietal region injury with ipsilateral facial symptoms is concerning for either mass effect or nerve injury. While 1 describes how parietal opercular-insular cortex lesions can produce pain syndromes, the localized tenderness and dermatomal numbness pattern here suggests peripheral nerve involvement rather than central pain.

Immediate Diagnostic Steps

Obtain urgent head CT without contrast to rule out:

  • Chronic subdural hematoma (can present weeks to months after trauma)
  • Skull fracture (may not have been symptomatic initially)
  • Epidural hematoma (though delayed presentation is rare, 2 documents cases 1.5 months post-injury)

If CT is negative or equivocal, obtain MRI brain with and without contrast to evaluate for:

  • Subtle fractures involving skull base
  • Nerve compression or injury
  • Soft tissue abnormalities

Treatment Algorithm

If Imaging Shows Structural Pathology:

  • Neurosurgical consultation immediately
  • Surgical intervention may be required for hematoma evacuation or decompression

If Imaging is Negative (Post-Traumatic Neuropathic Pain):

First-line pharmacological treatment 3:

Nortriptyline (secondary amine TCA):

  • Start: 10-25 mg orally at bedtime
  • Titrate: Increase by 10-25 mg every 3-7 days as tolerated
  • Target dose: 75-150 mg daily (keep <100 mg/day if cardiac concerns)
  • Advantages: Once-daily dosing, fewer anticholinergic effects than tertiary amines, inexpensive

Alternative first-line option - Gabapentin:

  • Start: 300 mg orally at bedtime on day 1
  • Day 2: 300 mg twice daily
  • Day 3: 300 mg three times daily
  • Titrate: Increase by 300 mg/day every 2-3 days
  • Target dose: 1800-3600 mg daily in 3 divided doses

For localized pain with tenderness, add: Topical lidocaine 5% patch:

  • Apply to painful area for up to 12 hours daily
  • Can be used alone or combined with systemic therapy 3

If Inadequate Response After 2-4 Weeks:

Add or switch to duloxetine:

  • Start: 30 mg orally daily for 1 week
  • Increase to 60 mg daily (maximum 120 mg daily if needed)

Or add pregabalin:

  • Start: 75 mg orally twice daily
  • Increase to 150 mg twice daily after 3-7 days
  • Maximum: 300 mg twice daily

For Breakthrough Pain:

Tramadol:

  • 50-100 mg orally every 4-6 hours as needed
  • Maximum: 400 mg daily
  • Use short-term during medication titration 3

Critical Pitfalls to Avoid

  1. Do not assume this is simple post-traumatic pain without imaging—delayed intracranial complications can be life-threatening
  2. Do not start TCAs without screening ECG if patient has cardiac history or is >40 years old
  3. Avoid tertiary amine TCAs (amitriptyline) due to higher anticholinergic burden; use nortriptyline or desipramine 3
  4. Monitor for orthostatic hypotension when starting TCAs, especially in combination with other medications
  5. Set realistic expectations: Neuropathic pain rarely resolves completely; goal is ≥50% pain reduction and improved function 3

Reassessment Timeline

  • Week 2-4: Assess pain reduction and adverse effects
  • If <30% pain relief: Switch to alternative first-line agent
  • If 30-50% relief: Add second first-line medication
  • If >50% relief with tolerable side effects: Continue current regimen
  • If multiple first-line combinations fail: Refer to pain specialist or neurologist 3

References

1
Research

Pain syndromes and the parietal lobe.

Handbook of clinical neurology, 2018

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