Bilateral nervus intermedius neuralgia with neurovascular contact: a case report highlighting hypertension and eczema as potential precipitating factors.

BACKGROUND: Nervus intermedius neuralgia (NIN) is a rare craniofacial pain syndrome. Bilateral involvement is extremely uncommon, and the pathophysiology and precipitating factors of NIN remain poorly understood. CASE PRESENTATION: A 57-year-old female presented with a 3-month history of bilateral paroxysmal stabbing deep ear pain triggered by cold wind and auricular pressure, superimposed on a persistent dull ache. She had a 5-year history of hypertension, with poor blood pressure control (140-160/90-105 mmHg) for four months preceding symptom onset. Otoscopic examination revealed bilateral external auditory canal eczema. Dedicated cranial MRI demonstrated bilateral anterior inferior cerebellar artery (AICA) loops in contact with the facial-vestibulocochlear nerve complexes, with no vascular contact at the trigeminal or glossopharyngeal nerves. A clinical diagnosis of bilateral NIN was established according to ICHD-3 criteria. The patient responded favorably to pregabalin combined with strict blood pressure control. At three-month follow-up, her stabbing pain had essentially resolved (VAS: 0-1/10). CONCLUSION: This first case of bilateral NIN with radiologically confirmed bilateral neurovascular contact supports neurovascular conflict as a pathophysiological mechanism even in bilateral presentations. Uncontrolled hypertension and local inflammation may serve as potential precipitating factors. A conservative approach combining pharmacotherapy with cardiovascular risk factor management may achieve favorable outcomes, potentially avoiding surgery in selected patients.