Sensory Innervation of the Head &

Functional Anatomy of Head Pain

Dr. Bader Khawaji
Dr. Ezidin Kadumi
 Learning Objectives
• Describe the nerve supply of head and neck with
special emphasis on pain.
• Describe the sensory pathway of trigeminal,
upper cervical, glossopharyngeal and vagus
nerves.
 Sensory Innervation of Head

• Most of the sensory information from head are

carried by Trigeminal nerve
– Trigeminal, facial, glossopharyngeal & vagus

• Spinal nerves (C1-C3) participate in the sensory

innervation of the head
Cranial Nerves: Types of Fibers
Sensory Innervation of face & scalp (GSA)
 External Nose (GSA)

• Nerve supply
– Infratrochlear (V1)
– External nasal (V1)
– Infraorbital (V2)
 Nasal Cavity Innervation
Trigeminal nerve (V1 & V2) & Olfactory nerve
 Paranasal Sinuses Innervation
• Maxillary sinus
• Superior alveolar nn. (V2)

• Frontal sinus
• Supraorbital nn. (V1)

• Sphenoid sinus
• Posterior ethmoidal nn. (V1)

• Ethmoid sinus
• Anterior & posterior ethmoidal nn.
From nasociliary n. (V1)
 Mouth: Sensory
Innervation
• Roof
– Nasopalatine nerve (V2)
– Greater & lesser palatine nerves
(V2)
– Glossopharyngeal nerve (IX)

• Cheek
– Buccal nerve (V3)
 Tongue Innervation
– Anterior ⅔
• Lingual nerve (V3)
• Chorda tympani (VII)

– Posterior ⅓ (IX)

– Base of tongue (X)

 Teeth Innervation

Upper teeth:
V2

Lower teeth:
V3
 Pharynx Sensory innervation

• Nasopharynx (V2)

• Oropharynx (IX)

• Laryngeopharynx
(X): internal
laryngeal nerve
 Larynx Sensory Innervation
• Sensory innervation (X)

• Above vocal cords:

internal laryngeal n.

• Below vocal cords:

recurrent laryngeal n.
 Temporomandibular Joint (TMJ)
Auriculotemporal (V3)

Masseteric (V3)
 Ear Sensory Innervation
• External ear:
– Great auricular n. (C2-C3) – auricle
– Auriculotemporal n. (V3) - auricle, external
auditory canal & eardrum (outer)
– Auricular branch of vagus - external auditory canal
& eardrum (outer)
– Glossopharyngeal n. – eardrum (inside)

• Middle ear
– Glossopharyngeal n. – tympanic plexus
 Eye Sensory Innervation

• Trigeminal nerve (V1)

– Long ciliary n.
– Short ciliary n.
 Dura Mater
• Cranial nerves V & X
– Referral pain to head from
above tentorium cerebelli

• Spinal nerves C1-C3

– Referral pain to back of
head & neck from bellow
tentorium
Trigeminal nerve (V) branches
 Trigeminal Nerve (V)
– Ophthalmic nerve (GSA) ← superior orbital fissure
trigeminal – Maxillary nerve (GSA)← foramen rotundum ← pterygopalatine
ganglion fossa
– Mandibular nerve (GSA, SVE) ← foramen ovale ← infratemporal
Brainstem fossa
 Ophthalmic Nerve

Frontal nerve
Scalp : Branches: Supraorbital & Supratochlear nn.
Lacrimal nerve
Lateral part of upper eyelid: Carry parasympathetic fibers to lacrimal gland via zygomaticotemporal nerve
 Ophthalmic Nerve: Branches
• Nasociliary nerve (GSA)
– Comunicating branch to ciliary ganglion-
sensory fibers from short ciliary nn.

– Long ciliary n. - carry sympathetic fibers

(dilator pupillae m.)

– Posterior ethmoidal n. (ethmoid &

sphenoid sinuses)

– Anterior ethmoidal n.
• External nasal branch (tip of nose), ethmoid sinus

– Infratrochlear n. (medial part of upper

eyelid & part of nose)
 Maxillary Nerve: Branches
• Menengial branches
• Zygomatic branch – inferior orbital fissure
– Zygomaticotemporal n. - Zygomaticotemporal foramen
– Zygomaticofacial n. - Zygomaticofacial foramen

• Ganglionic branches
– Greater & lesser palatine nn. – Greater & lesser palatine
canals/foramens
– Nasal branches (posterior superior lateral, posterior
superior medial, & nasopalatine nn.) – sphenopalatine
foramen
– Pharyngeal branch – pharyngeal canal

• Posterior superior alveolar n. – posterior superior

alveolar foramen

• Infraorbital nerve – inferior orbital fissure – infraorbital

groove – infraorbital foramen
• Middle superior alveolar n.
• Anterior superior alveolar n.
 Mandibular Nerve: Branches
• Meningeal branch – foramen spinosum
• Nerve to medial pterygoid

• Anterior division
– Masseteric n. (GSA, SVE)
– Deep temporal nn.
– Nerve to lateral pterygoid
– Buccal nerve (GSA)

• Posterior division
– Auriculotemporal n.(GSA)
• TMJ, middle menengeal a.
– Lingual n. (GSA)
– Inferior alveolar n. – mandibular foramen
• Mylohyoid n.
• Mental n. – mental foramen
 Facial Nerve (VII)
• Motor fibers (SVE) innervate facial,
scalp muscles
• Parasympathetic innervation (GVE)
to various glands in the head

• Sensory fibers (SVA) from taste buds

of tongue anterior 2/3rd
• Sensory fibers (GVA) from soft palate
• Sensory fibers (GSA) from external
ear
 All sensory fibers go to geniculate
ganglion (in facial canal)
 Facial Nerve (VII)
• (SVE, GVE,SVA,GVA,GSA)

• Pons (cerebellopontine angle)

• Internal acuastic meatus

• Facial canal

• Stylomastoid foramen
 Facial Nerve (VII)
• Greater petrosal nerve (GVE, GVA)↔
hiatus of the facial canal ↔ pterygoid
canal ↔ pterygpalatine ganglion

• Nerve to the stapidius muscle (SVE)

• Chorda tympani n. (GVE, SVA,GVA) ↔

canal in the tympanic cavity ↔ canal in the
petrotympanic fissure ↔ foramen at the
spine of sphenoid ↔ lingual nerve (V3)

• Posterior auricular n. (SVE)

– Stylohyoid & posterior belly of digastric

• Five terminal branches (SVE)

 Glossopharyngeal Nerve (IX)
• Medulla → Jugular foramen

• Motor fibers
– stylopharyngeus muscle
– parotid gland
 Function: regulation of secretion of saliva

• Sensory fibers originate from:

– GSA – superior ganglion – external ear
– GVA – inferior ganglion
• The pharynx & posterior ⅓ of tongue
• Carotid sinus baroreceptors
• Carotid body chemoreceptors
– SVA Taste buds of posterior 3rd of tongue
(taste) – inferior ganglion
 Glossopharyngeal Nerve (IX): Branches
• Tympanic n. → tympanic plexus (tympanic
cavity)→ lesser petrosal n. → fissure between
petrous portion & greater wing of sphenoid →
otic ganglion

• Carotid sinus n.

• Nerve to stylopharyngeus m.

• Pharyngeal branches → pharyngeal plexus*

• Lingual branch

*Contains fibers from:

IX – sensory & X – motor
sympathetic
 Vagus Nerve (X)
• Motor fibers: medulla
– SVE Muscles in respiratory passageways
– GVE Lungs, heart, esophagus, stomach,
small intestine, most of large intestine,
gallbladder

• Sensory fibers from:

– GSA The ear – superior jagular ganglion
– GVA Visceral sensory receptors of
thoracic and abdominal organs – inferior
nodose ganglion
– SVA Some taste buds – inferior nodose
ganglion
 Vagus Nerve (X): Branches
• Meningeal branch

• Auricular branch

• Pharyngeal branches → pharyngeal

plexus

• Superior laryngeal n.
– Internal laryngeal n.
– External laryngeal n.

• Recurrent laryngeal n. – left & right….

– Inferior laryngeal n.

• Cardiac branches → cardiac plexus

Sensory Pathway and Brainstem Nuclei
 Sensory Innervation of Head
Glossopharyngeal nerve
• GSA – external ear
Trigeminal nerve
• SVA – taste from tongue (posterior ⅓)
• GSA
• GVA – tongue (posterior ⅓), fauces,
• Skin of face and head pharynx, middle ear
• Mucus membrane
Vagus nerve
Facial nerve • GSA – external ear
• GSA – external ear & mastoid • SVA – taste base of tongue, epiglotis
• SVA – taste from tongue (anterior ⅔) • GVA – pharynx, larynx, other viscera
• GVA – soft palate , floor of the mouth,
pharynx Spinal nerves (C2-C3)
• GSA – scalp & dura mater
 Sensory Innervation of Head (1st order
neurons)

Trigeminal nerve Vagus nerve

• Trigeminal ganglion (V) – GSA
Facial nerve
• Geniculate ganglion (VII) – GSA,
GVA, SVA
• Glossopharyngeal nerve
• Superior ganglion (IX) – GSA
• Inferior ganglion (IX) – SVA, GVA
• Superior jugular ganglion (V) –
GSA
• Inferior nodose ganglion (V) –
GVA, SVA
Spinal nerves
• Dorsal root ganglion (C1-C3)
 Trigemino-cervical Complex

• Upper cervical afferents

converge to the pars
caudalis of spinal trigeminal
nucleus

• Cervical headache
(cervicogenic headache)
– Pain referred from cervical
origin to the head structures
 Trigemino-vascular system

• Cerebral & meningeal

vessels are innervated by
trigeminal nerve

• Pain afferents converge to

the spinal trigeminal
nucleus

• Migraine