“ However, on the morning after the accident, upon awakening he developed his first sharp twinge in the right occipital area. These severe stabbing head pains have occurred daily( up to 20 attacks per day) since the morning after the accident...”
“ However, on the morning after the accident, upon awakening he developed his first sharp twinge in the right occipital area. These severe stabbing head pains have occurred daily( up to 20 attacks per day) since the morning after the accident...”
2 weeks before the initial visit, following a minor motor vehicle accident in which his car was hit from behind while he was stopped at a red light. He did not notice any dizziness or light-headedness after the accident, and also denied any immediate pain or discomfort anywhere in his body. He noted that he did experience a whiplash motion in his neck, but he never addressed this complaint with his physician because it was very mild and initially, did not produce any neck and head pain. However, on the morning after the accident, upon awakening he developed his first sharp twinge in the right occipital area. These severe stabbing head pains have occurred daily( up to 20 attacks per day) since the morning after the accident. The patient tried taking acetaminophen and ibuprofen without any relief.
On physical examination, localized tenderness in the right suboccipital area( top of the neck) was noted. Palpation of the area was producing paresthesias( prickly and tingling sensations) along the path of the distribution of the right greater occipital nerve. When more intense pressure was applied to the area, the patient reported it was reproducing severe, short-lasting stabbing attacks. The range of motion in his neck was limited due to muscle tightness and to tenderness on the right side of the back of the head, above the neck. The rest of the neurological examination was normal. An x-ray of the cervical
spine( neck) appeared to be normal.
On the same day of the initial evaluation, a diagnostic right greater occipital nerve block to the affected region was performed and which produced immediate and complete resolution of the pain. The patient reported that the relief lasted for several hours, after which the pain attacks returned, but were less frequent. Several days later, at a follow-up appointment, the patient was started on baclofen( Lioresal ®) 10 mg. three times daily and carbamazepine( Tegretol ®) 100 mg. orally twice daily. The dose of carbamazepine was gradually increased to 600 mg. per day, at which point the pain ceased. The patient continued the therapy for an additional 4 weeks. Blood tests, including a complete blood count and comprehensive metabolic profile, were checked prior to initiation of carbamazepine treatment and repeated again 4 weeks into the treatment. The blood tests appeared to be within normal limits on both occasions. After the patient remained pain-free for 4 weeks, the baclofen and carbamazepine were weaned and discontinued. During a 1-month follow-up appointment, the patient remained symptom-free. HW
Alexander Feoktistov, MD, PhD. Diamond Headache Clinic Chicago, IL
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