Eye pain is a surprisingly common complaint after concussion.
Some people describe aching behind the eyes. Others experience pressure around the eye sockets, pain with reading, headaches after using a computer, or sharp discomfort when looking in a particular direction.
For some, the pain occurs every day.
And one of the most frustrating situations occurs when someone has already completed vision therapy, their eye movements or visual skills have improved, but the pain hasn’t gone away.
Why?
Because visual function and pain are not necessarily the same problem.
Understanding that distinction can open the door to looking at post-concussion eye pain differently.
Eye Pain Doesn’t Always Mean Something Is Wrong With the Eye
When your eye hurts, it seems logical to assume that the problem must be within the eyeball itself.
Sometimes it is. Eye disease, inflammation, infection, glaucoma, corneal problems, and other ophthalmological conditions can cause ocular pain and need appropriate medical evaluation.
But following concussion or head and neck trauma, pain around or behind the eyes can also involve the nervous system, extraocular muscles, surrounding tissues, neck, and pain-processing pathways.
That is why someone can have significant eye pain despite being told that the eyes themselves look healthy.
The Trigeminal Nerve: A Major Pain Pathway
One important piece of this puzzle is the trigeminal nerve.
The trigeminal nerve is the major sensory nerve of the face and head. Its ophthalmic division—often called V1—carries sensory information from areas that include the forehead, upper eyelid, cornea, and structures around the eye.
It is also deeply connected with neurological pathways involved in headache and migraine.
Following a concussion, the trigeminal system may be one of several systems contributing to persistent head, facial, or orbital pain.
This becomes particularly interesting when the pain changes depending on where the eyes are looking.
Does It Hurt When You Look in a Certain Direction?
This is something we specifically investigate in patients with persistent post-concussion eye and head pain.
Try thinking about your own symptoms.
Does looking up hurt?
What about looking down?
Does looking far to the right or left produce an ache behind one eye?
Do diagonal eye movements feel different?
Does holding your eyes in one position make the pain gradually build?
Does looking at something close to your face hurt more than looking into the distance?
These patterns can provide valuable information.
We use the term gaze-evoked ocular or orbital pain to describe pain in or around the eye that can be reliably triggered or changed by moving the eyes into particular positions or sustaining a particular direction of gaze.
The key word is reproducible.
If looking in a certain direction repeatedly produces the same pain, that pattern deserves closer investigation.
Your Eye Muscles Are Part of the Story
Six extraocular muscles control the movement of each eye.
These muscles allow us to look up, down, left, right, diagonally, and rotate the eyes slightly as the head changes position.
They do not work independently. Eye movements are controlled by an extraordinarily sophisticated neurological system involving cranial nerves, the brainstem, cerebellum, vestibular system, visual pathways, and other brain networks.
Following head trauma, symptoms can sometimes emerge when these systems are challenged.
For example, pain may appear when a particular eye muscle is activated, when the eyes are held in an eccentric position, or when several systems are required to coordinate eye and head position simultaneously.
This doesn’t necessarily mean that the eye muscle itself is “damaged.”
It means we need to investigate what conditions reproduce the pain and why.
Why Can Vision Therapy Help My Vision but Not My Pain?
Vision therapy can be extremely valuable after concussion.
Depending on the problem, rehabilitation may address convergence, focusing, eye tracking, visual processing, coordination between the eyes, and other visual functions.
But consider an important distinction:
An eye movement can become more accurate while still being painful.
Someone may improve their ability to converge their eyes, track a moving target, or perform a visual exercise—and still develop a headache every time they use those systems for an extended period.
In that situation, simply doing more of the same exercise may not address the entire problem.
The question changes from:
“Can the eyes perform the movement?”
to:
“Why does performing this movement hurt?”
Those are different clinical questions.
When Eye Pain Becomes Head Pain
The neurological pathways carrying sensory information from around the eye do not operate in isolation.
Trigeminal pain pathways interact with structures in the brainstem and upper cervical nervous system. This creates important connections between sensory information coming from the eyes, face, head, and upper neck.
This may help explain why some patients experience symptoms that seem to spread.
Eye strain becomes orbital pain.
Orbital pain becomes a headache.
Neck pain accompanies pain behind the eye.
Looking in a particular direction produces pain that extends into the forehead or temple.
Rather than assuming these are several unrelated problems, we can investigate whether they are different expressions of interacting sensory and pain-processing systems.
A More Detailed Assessment of Post-Concussion Eye Pain
If someone has persistent eye or orbital pain, simply asking whether their vision is blurry may not provide enough information.
We want to map the pain.
That may include evaluating:
- •Pain when looking straight ahead
- •Right and left gaze
- •Looking upward and downward
- •Diagonal eye positions
- •Sustained gaze
- •Convergence
- •Eye tracking
- •Rapid eye movements
- •Head movement compared with eye movement
- •Head tilt and changes in head position
- •Differences between the right and left eye
- •Neck movement and cervical contributions
- •Tenderness around specific orbital structures
- •Vestibular and visual interactions
We can also compare symptoms under different sensory conditions.
For example:
Does the movement hurt with the eyes open but not closed?
Does moving the eyes reproduce the pain while turning the head toward the same target does not?
Does changing head position alter the painful eye movement?
Those comparisons can help us tease apart the different neurological and musculoskeletal contributors to the pain.
Sometimes the Pain Is the Finding
This is an important concept.
A traditional eye-movement examination may focus primarily on whether the eyes can move appropriately.
But the patient’s experience during that movement also matters.
An eye movement can look relatively normal to an observer while producing significant pain for the patient.
That pain is not something we necessarily want to dismiss as simply “eye strain.”
The pattern of pain itself can provide useful clinical information.
What Can Be Done About It?
Once we have a better understanding of which movements, tissues, and neurological systems appear to be contributing to the pain, treatment can become more individualized.
At Healing Response, we may use a combination of hands-on and hands-off strategies, depending on the findings.
Hands-on approaches may address relevant muscles, soft tissues, cervical structures, and other musculoskeletal contributors.
Hands-off neurological rehabilitation may involve carefully selected eye movements, head and eye coordination, vestibular activities, sensory stimulation, proprioceptive strategies, or modifications to how a particular visual task is performed.
Acupuncture and other therapeutic approaches may also be incorporated when appropriate.
Most importantly, we can test, treat, and reassess.
If a particular intervention changes the painful eye movement immediately, that gives us additional information that can help guide the rehabilitation plan.
Still Having Pain After Vision Therapy?
If you’ve already completed vision therapy but continue to experience daily headaches, pain behind your eyes, or pain when reading, working on a computer, or moving your eyes, that doesn’t necessarily mean you’ve exhausted your options.
It may mean that another piece of the problem needs to be investigated.
Your visual abilities may have improved while the systems contributing to pain remain sensitive or dysfunctional.
At Healing Response Acupuncture & Functional Neurology, we take an in-depth approach to persistent ocular, orbital, and gaze-evoked pain following concussion. Rather than looking only at whether the eyes can perform a particular task, we examine what happens when they do it.
Where does it hurt?
Which movement triggers it?
What changes it?
How do the eyes interact with the vestibular system, trigeminal pathways, neck, and the rest of the nervous system?
And most importantly:
Can we find ways to perform those movements with less pain?
For people who have been living with persistent eye pain and daily headaches after concussion, asking these more specific questions can reveal treatment opportunities that may previously have been overlooked.