Nasal Bridge Pain (Charlin's Neuralgia)

Rarely, I have seen a patient with pain located exactly over the nasal bridge skin surface on one side that may radiate into the eye. This pain often occurs after nasal trauma of some kind or surgery, typically septoplasty. There are no physical abnormalities on exam either clinically or on endoscopy. Imaging studies invariably all come back normal.

Associated symptoms may include upper facial and ocular pain as well as severe same one sided runny nose, mucosal congestion, and eye redness.

The theory behind this pain is due to a rare atypical neuropathy known as nasociliary neuropathy/neuralgia, otherwise known as Charlin's Neuralgia. It is a neuralgia involving the peripheral trigeminal nerve branch of V1 as opposed to the main V2 nerve trunk which is classically seen with trigeminal neuralgia causing pain involving the entire cheek and nose on just one side. With Charlin's Neuralgia, only the nasociliary nerve branch of V1 is affected. This nerve exits from within the nose to the nasal skin surface between the nasal bone and nasal cartilage.

This condition can be confused with the more common Cluster Headache as both conditions can cause eye and nasal pain in just one side, have rapid onset to peak of pain, duration of attacks are relatively short, attacks occur in paroxysms, pain free between attacks, and causes one-sided runny nose. But there are a few clues to help differentiate between Cluster Headache and Charlin's Neuralgia.

The following are true for Cluster Headaches, but not Charlin's Neuralgia:

- alcohol can trigger attacks
- seasonal pattern to attacks
- chronobiological pattern to attacks (ie, menstrual cycle)
- responds to sphenopalatine ganglion block, but not nasociliary block

The following is true for Charlin's Neuralgia but not Cluster Headaches:

- there are tactile trigger points
- significant eye inflammation with attacks
- responds to nasociliary block, but not sphenopalatine ganglion block

Most of the time, this pain slowly dissipates over months without any treatment, but occasionally, some patients may require treatment with drugs to address a non-resolving neuropathic pain. Such meds include neurontin, elavil, lyrica, cymbalta, etc. If meds do not work, injection to the painful site with a numbing and/or steroid agent (nasociliary and/or sphenopalatine nerve block).

Cluster headaches and Charlin's neuralgia are mainly treated by neurology, some ENT, and some pain-specialists.

References:

Charlin’s Syndrome Following a Routine Septorhinoplasty. World J Plast Surg. 2018 Jan; 7(1): 103–108.

External Nasal Neuralgia: an Update. Curr Pain Headache Rep. 2017 Sep 13;21(11):44. doi: 10.1007/s11916-017-0645-5.