What are the possible causes and treatments for pain above the right eye?

Pain Above Right Eye: Differential Diagnosis and Management

Pain above the right eye requires systematic evaluation to distinguish between ophthalmologic, neurologic, and vascular etiologies, with the most common causes being inflammatory eye disease (69% of cases), migraine (51% in neurology clinics), and neuropathic pain conditions. 1

Initial Diagnostic Approach

Critical Red Flags to Assess Immediately

• Giant cell arteritis must be ruled out urgently in patients over 50 years old, as this requires immediate corticosteroid treatment to prevent vision loss 2
• Acute angle-closure glaucoma presents as an ophthalmologic emergency requiring immediate referral 3, 4
• Progressive neuropathic pain may indicate underlying malignancy 2

Key History Elements

Determine the following specific characteristics 5:

• Pain quality: burning, stinging, aching, electric shock-like, or throbbing 2
• Temporal pattern: acute vs. chronic, continuous vs. episodic 2
• Associated symptoms: photophobia, wind sensitivity, visual changes, headache 2, 5
• Systemic conditions: fibromyalgia, migraine history, recent trauma or surgery 2
• Medication history: topical eye drops, especially glaucoma medications 2

Common Etiologies by Category

Inflammatory Eye Disease (Most Common Overall)

Inflammatory conditions account for approximately 69% of eye pain presentations and include conjunctivitis, blepharitis, keratitis, dry eye, and scleritis 1. These conditions typically present with:

• Symptoms that correlate with observable ocular surface abnormalities 2
• Response to topical lubricants and anti-inflammatory treatment 5
• Positive fluorescein staining showing epithelial defects 5

Neuropathic Ocular Pain (NOP)

Neuropathic pain is characterized by symptoms that outweigh clinical signs, making it frequently misdiagnosed 2, 5. Key diagnostic features include:

• Burning pain quality with sensitivity to wind and light 2
• Symptoms persisting despite appropriate treatment of ocular surface abnormalities 2
• Pain that may be disconnected from ongoing peripheral signs 2

The anesthetic challenge test is critical for diagnosis: instill topical anesthetic when pain is present; improvement suggests peripheral neuropathic or nociceptive pain, while persistent pain indicates central or non-ocular causes 2, 5

Migraine and Primary Headache Disorders

Migraine is the predominant cause of eye pain in neurology clinics (51% of cases) 1. Consider this diagnosis when:

• Pain is episodic and throbbing in nature 2
• Associated with photophobia and systemic headache symptoms 2
• The eye examination is otherwise unremarkable 3

Trigeminal Neuralgia

This presents as severe, electric shock-like pain provoked by light touch and responds best to carbamazepine 2

Diagnostic Testing Algorithm

Initial Examination

1. Visual acuity assessment and pupillary examination 6, 4
2. Slit-lamp biomicroscopy to evaluate conjunctiva, cornea, and anterior chamber 6, 4
3. Fluorescein staining to assess corneal epithelial integrity and tear break-up time (perform before any other drops are instilled) 2, 5
4. Intraocular pressure measurement to rule out glaucoma 6, 4

Advanced Testing When Indicated

• Anesthetic challenge test for suspected neuropathic pain 2, 5
• OCT imaging to assess retinal nerve fiber layer if optic nerve pathology suspected 6
• Neuroimaging may be warranted for isolated chronic eye pain with normal examination, though usually normal 7

Treatment Approach Based on Etiology

For Inflammatory Eye Disease

Manage with ocular lubricants and treatment of underlying inflammation 5. This includes:

• Artificial tears for dry eye syndrome 5
• Topical antibiotics for infectious conjunctivitis or keratitis 2
• Discontinuation of offending medications if medication-induced keratoconjunctivitis suspected 2

For Peripheral Neuropathic Ocular Pain

Topical nerve regenerative therapies are first-line, specifically autologous serum tears 2, 5

For Central Neuropathic Pain or Systemic Comorbidities

Oral neuromodulators are indicated, including pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone, used alone or in combination 2, 5

Critical counseling point: All neuromodulators require 3-4 months at therapeutic dose to see pain reduction; set expectations early to ensure treatment adherence 2

For Light Sensitivity and Headache Component

Consider adjuvant migraine strategies 2:

• Transcutaneous electrical nerve stimulation devices 2
• Periorbital botulinum toxin A injections 2

For Cutaneous Allodynia or Post-Surgical Pain

Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker can be effective 2

Multidisciplinary Management

Neuropathic ocular pain warrants involvement of ophthalmologists, pain specialists, neurologists, and mental health professionals 2. Patients often experience concomitant anxiety and depression due to chronic pain 2. Complementary therapies to consider include:

• Cognitive behavioral therapy 2
• Acupuncture 2
• Hypnosis 2

Common Pitfalls

• Misdiagnosing neuropathic pain as dry eye because symptoms outweigh signs 2, 5
• Using fluorescein-anesthetic combination drops for tear break-up time testing, as anesthetic affects results 2, 5
• Failing to distinguish giant cell arteritis from temporomandibular disorders in patients over 50 2
• Discontinuing neuromodulators prematurely before the 3-4 month therapeutic window 2
• Missing the need for ophthalmology-neurology collaboration when diagnosis remains unclear 1