This chapter provides a comprehensive review of intermediate nerve neuralgia, a rare and often underdiagnosed condition characterized by brief paroxysms of pain felt deep within the auditory canal and the periauricular region. Symptomatic overlap with other cranial neuralgias makes early recognition and accurate diagnosis essential. Patients typically present with episodes of shock-like pain, which may be triggered by stimulation of the posterior wall of the auditory canal or the periauricular region. The case report describes a 58-year-old woman who, following an episode of facial paralysis without the development of auricular vesicles, began experiencing short-lasting paroxysmal pain in the ear, with a periauricular trigger zone. The diagnostic approach relies primarily on clinical evaluation, with neuroimaging playing a key role in identifying structural causes. High-resolution magnetic resonance imaging (MRI) with Fast Imaging Employing Steady-State Acquisition (FIESTA) sequencing is particularly useful for detecting neurovascular conflicts, demyelination, or expansive lesions. First-line treatment includes neuromodulators such as carbamazepine, oxcarbazepine, and gabapentinoids, as well as tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors, which may provide additional benefits. In refractory cases, minimally invasive procedures, such as intermediate nerve blocks with local anesthetics and botulinum toxin type A injection—widely used in other cranial neuralgias—may be considered. However, robust clinical evidence for its use in intermediate nerve neuralgia is still lacking. In cases where a neurovascular conflict is identified, surgical treatment with vascular decompression may be a viable option. For refractory patients without evidence of neurovascular conflict, strategies such as nerve sectioning, rhizotomy, and tractotomy may be considered, particularly when pain is debilitating and resistant to all conservative approaches.