130 Headache Medicine, v.8, n.4, p.130-133, Oct./Nov./Dec. 2017
Supraorbital foramen or notch and its relationship with
the supraorbital nerve in human
Forame supraorbital ou entalhe e sua relação com o nervo supraorbital em humanos
Maria Rosana de Souza Ferreira
1,3
, Renata Cristinny de Farias Campina
2
,Carolina Peixoto Magalhães
1
,
Marcelo Moraes Valença
3
1
Departamento of Anatomy, Academic Center of Vitória of Santo Antão, Vitória de Santo Antão;
2
Departamento of Anatomy
3
Unit of Neurosurgery, Department of Neuropsychiatry, Recife, Federal University of Pernambuco, Pernambuco, Brazil
Ferreira MRS, Campina RCF, Magalhães CP, Valença MM. Supraorbital foramen or notch and its relationship with the
supraorbital nerve in human. Headache Medicine. 2017;8(4):130-133
ORIGINAL ARTICLE
INTRODUCTION
Recently, with the growing use of nerve infiltration with
anesthetic/corticoid substances to treat different types of head
pain, including primary (e.g. migraine and cluster headache)
and secondary headaches, the study of the anatomy of the
nerves situated in close contact with the skull is of utmost
importance to enable specialists to treat their patients
satisfactorily.
(1,2)
The frontal region is probably the commonest location
where the pain is experienced by the large majority of
patients with headache.
(3)
Two important nerves innervate
this region: the supraorbital and supratroclear nerves. Both
these nerves originate in the frontal nerve, branch of the
ophthalmic nerve (the first trigeminal branch), within the
orbital cavity and, to reach the frontal area, they pass over
the superior orbital rim.
(4)
In the superior orbital rim, they
usually cross from the orbital space to the frontal region
through a foramen or notch, named supraorbital foramen
or notch. There are many anatomical variations in these
structures that need to be studied further, particularly those
associated with sex. A spectrum from absence of a notch to
a foramen, including different degrees of tunnelization and
an almost complete foramen, can be seen in the orbitofrontal
region of the skull.
(5,6)
The purpose of this study is to present some anatomical
features of the superior orbital rim and the passage of the
supraorbital nerve through a foramen or more frequently a
notch.
ABSTRACT
Currently, interventions with anesthetic substances have been
an alternative for headache treatment. There are some
regions that are targeted for the application of anesthetics,
such as the upper margin of the orbit, where two critical
nerves, supratrochlear and supraorbital, pass. The objective
of this study is to present some anatomical features
characteristic of the superior orbital border and passage of
the supraorbital nerve through a foramen or more often
notch. Dry skulls from male and female individuals were
used, measures were taken to compare the distance between
the foramen and the median line of the skull. The length was
measured and compared between the sexes, obtaining the
following results in men (2.27 ± 0.29 cm) and women (2.18
± 0.41 cm). The collected data are of extreme importance
to understand the anatomy of the region and intervention in
procedures of infiltrations and treatment of headache.
Keywords: Supraorbital nerve; Supratrochlear nerve;
Anatomy; Infiltration; Orbit
Headache Medicine, v.8, n.4, p.130-133, Oct./Nov./Dec. 2017 131
MATERIAL AND METHOD
Study population
Forty adult human skulls of both sexes (20 males and
20 females) were used in this study, belonging to the
Human Adult Bone Collection of the Academic Center of
Vitoria, Federal University of Pernambuco, Brazil. A foramen
was defined as a canal connecting the orbital space to
the frontal region, including the orbital rim (=360°). A
partial foramen was identified when a notch presented an
arc of at least 180 degrees, creating an open tube. A
notch was identified when the arc was smaller than 180
degrees.
Measurements
After identification of the structure (notch, partial
foramen or foramen), the distance between the median line
of the skull and the medial and lateral border of the identified
structure was measured. To mark the midline of the skull, a
straight line was drawn with cotton thread # 10, attached
to the medial palatine suture to the glabella in the frontal
bone. The measurement was then performed using a 150
mm stainless steel digital caliper - Lee Tools® (Figure 1).
Statistical analysis
To test the distribution of values in the population, the
samples were combined between the sexes, using the Mann-
Figure 1. Method used to measure the distance between the medial border (in red) and the lateral border (in yellow) of the supraorbital notch/
foramen to the midline of the skull (in blue).
Whitney statistical test, or the Student t-test, depend on the
distribution evaluated with the K-S test, with the program
GraphPad Prism 7.02. The mean value was compared with
the paired sample, and a P value <0.05 was considered
significant in all analyzes.
RESULTS
Table 1 shows the data comparing male and female
skulls in relation to foramina or notches. The different forms
of foramina can be seen in Figure 2 (A and B). Figure 2
shows the different variations encountered in the notches.
A vascular foramen (arrow) is shown in Figure 3. Note
that there is no orbital orifice to form a supraorbital
foramen.
The distance between the median line of the skull
and the medial border of the supraorbital foramen was
measured in men (2.27 ± 0.29 cm; minimum 1.72 cm
– maximum 2.92 cm) and women (2.18 ± 0.41 cm;
minimum 1.36 cm – maximum 3.20 cm), with no
statistical difference between sexes (p>0.05, Figure 4),
Student t-test.
Figure 5 shows the upper margin of the left orbit, in
an adult cadaver specimen, with the following structures
from medial to lateral aspect: (1) supratrochlear nerve,
(2) supraorbital artery and (3) supraorbital nerve, which
travels through the supraorbital incisura.
SUPRAORBITAL FORAMEN OR NOTCH AND ITS RELATIONSHIP WITH THE SUPRAORBITAL NERVE IN HUMAN
132 Headache Medicine, v.8, n.4, p.130-133, Oct./Nov./Dec. 2017
FERREIRA MRS, CAMPINA RCF, MAGALHÃES CP, VALENÇA MM
Figure 4. The distance between the median line of the skull and the
medial border (upper panel) or lateral border (lower panel) of the
supraorbital foramen.
Figure 2. Foramina/notches. A) Left supraorbital foramen; B) existence
of two supraorbital foramina; C) only a slight bone depression is observed;
and D) partial closure of the notch, forming a partial foramen.
Figure 5. Upper margin of the left orbit, showing the following structures
from medial to lateral: supratrochlear nerve (yellow point); supraorbital
artery (red point); supraorbital nerve (blue point), which travels through
the supraorbital incisura or foramen. supraorbital artery (red point);
supraorbital nerve (blue point).
Figure 3. Vascular foramen (arrow). Note that there is no orbital orifice
to form a supraorbital foramen.
COMMENT
The females presented a larger number of foramina
that the males. Anatomical variation was frequently
encountered in foramina and notches, even when the right
and left sides were compared in the same individual. In a
few individuals two supraorbital foramina were found.
Curiously, sometimes a vascular canal may be mistaken for
Headache Medicine, v.8, n.4, p.130-133, Oct./Nov./Dec. 2017 133
a supraorbital foramen, but in this case the orbital orifice
cannot be seen as in the case of the foramen where both
orbital and frontal orifices are encountered.
For safe surgical approaches it is necessary to have
knowledge of the access bone regions.
(7)
However, as seen,
there is a frequent variation in the location and shape of
the supraorbital foramina, since they are structures of
passage of the branch of the supraorbital nerve, it is
necessary that there is understanding about the anatomy of
these structures, since very often the foramen has been
accessed for the treatment of diseases, as is the case of the
headaches.
(5,8)
REFERENCES
1. Gelfand AA, Reider AC, Goadsby PJ. Outcomes of greater occipital
nerve injections in pediatric patients with chronic primary headache
disorders. Pediatr Neurol. 2014 Feb;50(2):135-9.
2. Pehora C, Pearson AM, Kaushal Um, Crawford MW, Johnston
B. Dexamethasone as an adjuvant to peripheral nerve block.
Cochrane Database Syst Rev. 2017 Nov 9;11:CD011770.
3. Berchtold V, Stofferin H, Moriggl B, Brenner E, Pauzenberger R,
Konschake M. The supraorbital region revisited: An anatomic
exploration of the neuro-vascular bundle with regard to frontal
migraine headache. J Plast Reconstr Aesthet Surg. 2017 Sep;70
(9):1171-1180
4. Pareja JA, López-Ruiz P, Mayo D, Villar-Quiles RN, Cárcamo A,
Gutiérrez-Viedma Á, et al. Supratrochlear Neuralgia: A Prospective
Case Series of 15 Patients. Headache. 2017;57(9):1433-42.
5. Woo SW, Lee HJ, Nahm FS, Lee PB, Choi EJ. Anatomic
characteristics of supraorbital foramina in korean using three-
dimensional model. Korean J Pain. 2013 Apr;26(2):130-4.
6. Mishra A, Shrestha S, Singh M. Varying positions and
anthropometric measurement of supraorbital and supratrochlear
canal/foramen in adult human skulls. Nepal Med Coll J. 2013
Jun;15(2):133-6.
7. Mehta MP, Chundury RV, Ahn ES, Mehta D, Jellema LM, Perry
JD. Predictability of Optic Foramen Location From a Ray Through
the Ethmoidal Foramina. Ophthalmic Plast Reconstr Surg. 2016
Nov/Dec;32(6):481-3.
8. Garg RK, Lee KS, Kohn SC, Baskaya MK, Afifi AM. Can
Sonography Distinguish a Supraorbital Notch From a Foramen?
J Ultrasound Med. 2015 Nov;34(11):2089-91.
SUPRAORBITAL FORAMEN OR NOTCH AND ITS RELATIONSHIP WITH THE SUPRAORBITAL NERVE IN HUMAN
Correspondence
Marcelo Moraes Valença, MD, PhD
Unit of Neurosurgery, Department of Neuropsychiatry, Recife,
Federal University of Pernambuco, Pernambuco, Brazil
mmvalenca@yahoo.com.br
Received: November 2, 2017
Accepted: December 28, 2017
