“ 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
www . headaches . org | National Headache Foundation 15