What is the treatment for pain below the left eye and above the right eye?

Treatment for Pain Below Left Eye and Above Right Eye

Pain below the left eye and above the right eye should be evaluated for neuropathic ocular pain (NOP) first, with treatment determined by whether the pain has peripheral or central components. 1

Diagnostic Approach

Initial Assessment

• Perform "anesthetic challenge test" - if pain improves with topical anesthetic, suggests nociceptive or peripheral neuropathic component; if no improvement, suggests central or non-ocular cause 1
• Evaluate tear film parameters and ocular surface for:
  • Aqueous tear deficiency
  • Tear film instability
  • Inflammation
  • Epithelial erosions 1
• Assess for symptoms that outweigh observable signs (characteristic of NOP)
• Use specialized questionnaires like Neuropathic Pain Symptom Inventory (NPSI)-Eye or Ocular Pain Assessment Survey (OPAS) to identify neuropathic pain qualities 1

Differential Diagnosis

1. Ocular surface disorders:

   • Dry eye syndrome
   • Superior limbic keratoconjunctivitis
   • Contact lens-related keratoconjunctivitis 1

2. Facial pain conditions:

   • Temporomandibular disorders (TMDs)
   • Trigeminal neuralgia 1

3. Other conditions:

   • Acute angle closure glaucoma (severe pain, requires urgent treatment) 1
   • Optic neuritis (typically with vision changes) 2

Treatment Algorithm

1. For Peripheral NOP (Corneal Neuropathic Pain)

• First-line: Topical nerve regenerative therapies
  • Autologous serum tears 1
  • Preservative-free artificial tears 1

2. For Central NOP or Systemic Comorbidities

• First-line: Oral neuromodulators
  • Pregabalin
  • Gabapentin
  • Duloxetine
  • Amitriptyline
  • Nortriptyline
  • Low-dose naltrexone 1

3. For Light Sensitivity and Headache

• Transcutaneous electrical nerve stimulation device
• Periorbital botulinum toxin A injections 1

4. For Cutaneous Allodynia or Postsurgical Pain

• Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker 1

Important Clinical Considerations

1. Treatment duration: Neuromodulators require 3-4 months at therapeutic dose to show pain reduction. Set proper expectations with patients about timeline for relief 1

2. Combination approaches: Often multiple treatment modalities are needed simultaneously 1

3. Psychological factors: Address concomitant anxiety and depression that often accompany chronic pain 1

4. Red flags requiring urgent referral:

   • Severe unilateral pain with redness (possible acute angle closure glaucoma) 1
   • Pain with vision loss (possible optic neuritis) 2
   • Pain in patients >50 years with temporal tenderness (possible giant cell arteritis) 1
   • Progressive neuropathic pain (possible malignancy) 1

5. Multidisciplinary approach: Consider referrals to pain specialists, neurologists, and mental health professionals for comprehensive management 1

Adjunctive Therapies

• Acupuncture
• Cognitive behavioral therapy
• Hypnosis 1

Remember that facial pain can have dental or non-dental origins, and the diagnostic pathway may differ depending on whether a patient initially consults a dentist or medical practitioner 1. For persistent symptoms despite appropriate treatment, consider a multidisciplinary pain management approach.