What are the treatment options for great auricular neuralgia?

Treatment and Management of Great Auricular Neuralgia

First-Line Treatment Approach

Great auricular neuralgia should be treated initially with either gabapentin or ultrasound-guided nerve blocks with local anesthetics and steroids, as both provide complete pain relief in the majority of cases. 1, 2, 3

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by:

• Identifying pain location: Strictly unilateral pain in the preauricular region, jaw angle, posteroinferior pinna, and mastoid region 1, 4
• Testing for trigger points: Pain triggered by pressing the preauricular area, turning the head, touching the neck, or jaw movement 1, 4
• Assessing pain quality: Background dull pain (intensity 5-6/10) with burning paroxysmal exacerbations lasting seconds to 30 minutes (intensity 7-8/10) 1
• Consider electrophysiologic examination: This can definitively diagnose GAN lesions when the clinical picture is unclear or overlaps with trigeminal or occipital neuralgia 3

Medical Management

Gabapentin is the preferred oral medication, achieving complete pain relief in approximately 38% of patients as monotherapy 1:

• Start gabapentin at standard neuropathic pain dosing
• This represents a good alternative to invasive procedures 1
• Other neuropathic pain medications (anticonvulsants, antidepressants) have been tried but show limited efficacy 2, 3

Avoid relying on simple analgesics and NSAIDs, as they are consistently ineffective for this neuropathic condition 2, 3

Interventional Treatment

Ultrasound-guided great auricular nerve blocks provide immediate and complete pain relief 2, 3, 4:

• Use local anesthetics combined with steroids 3
• Approximately 54% of patients achieve dramatic improvement with nerve blocks 4
• Serial blocks can be administered successfully for 2-5 years in patients requiring ongoing treatment 4
• All patients who received GAN blocks in reported series noted dramatic pain improvement 4

For refractory cases, consider combined nerve blocks: When GAN block alone provides only partial relief, add C2 and C3 facet blocks for more pronounced and prolonged benefit 5. This addresses the ansa cervicalis network connections that may contribute to complex presentations with dysautonomia, tongue tingling, dysphagia, or dysarthria 5.

Advanced Treatment Options

Great auricular nerve stimulators are effective for patients requiring long-term management 4:

• Two patients successfully transitioned from serial GAN blocks to permanent stimulators 4
• Consider this option for patients responding well to blocks but requiring frequent repeat procedures 4

Surgical resection is reserved for structural pathology: One patient with GAN lymphoma achieved complete pain resolution following nerve resection 4. This is not indicated for idiopathic neuralgia.

Treatment Algorithm

1. Initial trial: Start gabapentin for 2-4 weeks 1
2. If inadequate response: Proceed to ultrasound-guided GAN block with local anesthetic and steroid 2, 3
3. If partial response to GAN block: Add C2/C3 facet blocks 5
4. If requiring serial blocks: Consider transition to GAN stimulator 4
5. If bilateral presentation: Treat both sides, as bilateral cases have been reported 2

Common Pitfalls

• Do not misdiagnose as trigeminal neuralgia: GAN neuralgia has distinct trigger points in the neck and preauricular region, not the typical trigeminal trigger zones 3
• Do not rely on imaging alone: Cervical and brain imaging are typically normal; diagnosis is clinical with confirmation by response to nerve block 2, 5, 3
• Do not use systemic antibiotics or treat as infection: This is a neuropathic pain condition, not infectious 2, 3
• Do not overlook cervical plexus connections: Pain may be accompanied by symptoms from the ansa cervicalis network requiring combined treatment approach 5

Expected Outcomes

• Spontaneous resolution: Occurs in approximately 25% of cases 1
• Complete relief with treatment: Achieved in 75% of patients using gabapentin or nerve blocks 1
• Immediate response to nerve block: Diagnostic and therapeutic, with pain subsiding immediately after properly performed block 2, 3