A 58-year-old woman who had been experiencing headaches was referred to me at my pain-management practice.

Her pain occurred on and off for nearly two years, starting at the base of her skull. Consistently, the pain would radiate to her forehead, mainly on the right side, and at times, was stabbing in its intensity. The pain could last anywhere from 15 minutes to a few hours. Recently, she complained that her scalp felt numb when she brushed her hair, and noted pain behind her right eye.

After she tried pain medication, physical therapy and massage to the area, muscle relaxants, anti-seizure medications, and chiropractic treatments, her doctor performed various diagnostic tests. An MRI of the brain and sinuses, and a full eye exam all came back normal. This was good news, as it ruled out some more serious causes of headaches that can be located in the brain, sinuses, or the eyes, such as brain tumors, sinus polyps, or glaucoma.

When she came to my office for an exam, I first sought to rule out migraine, tension or cluster headaches. Migraine pain is more common in women, may be preceded by a visual aura, tends to occur on one or both sides, and may last up to two hours. Tension headaches often occur with stress and feel more like a tight band around the head. Cluster headaches occur more often in men, are severe in intensity, come in cycles, often waking a sleeping patient, and may last several hours.

During my exam, she did not complain of a headache. I put pressure over certain bony landmarks in the back of her skull, in the occipital area — near where the head meets the spine — which did not elicit pain. However, when I manipulated the cervical area of the spine — located in the neck region — I noted the patient’s lack of flexibility, as well as tenderness of the cervical muscles that ran over the neck.

Based on her exam and recent symptoms of scalp numbness, along with the pain behind her right eye, I performed an additional test, using electro-stimulation of the occipital nerve, at the base of the neck, on her right side. I carefully placed an electrode through a needle and ran a small amount of current directly to the nerve root. By doing this, I stimulated, and thus irritated, the nerve, hoping to produce and mimic her pain and trace the nerve’s route to see whether the pain followed it. The test successfully reproduced the exact pain she had been complaining of, in its location and intensity and helped me identify the cause of her headaches

Solution

My test confirmed a diagnosis of occipital neuralgia. This is a condition where the occipital nerves, which originate from the top of the spinal cord and run up through the scalp, are inflamed or injured. Trauma to the back of the neck, osteoarthritis, neck muscle tension, cervical disc disease, and tumors of the neck are possible causes of this condition. In this patient’s case, the cause was likely trauma to the neck after a car accident.

This patient had been treated for migraines, unsuccessfully, since the symptoms can be similar to those of migraines, such as pain behind the eye, sensitivity to light, or pain while moving the neck.

A common treatment involves steroid injections to the inflamed area, which typically need to be repeated. Another option, which I suggested because it offers the hope of more extended or even permanent relief, is an ablation or rhizotomy of the occipital nerve.

The procedure, which was performed while the patient was awake, was similar to the initial diagnostic electro-stimulation procedure. I injected an anesthetic to the nerve root, and then applied a higher electrical current, set at double the diagnostic current, to the nerve. It effectively cauterized — or burned — the nerve, which relieved her pain.

The patient was mildly uncomfortable for five days following the procedure, but there were no other long-term side effects, nor was there lingering numbness in the area.

She was symptom free at the six-month and one-year rechecks. Long term, the nerve may regenerate, and symptoms may or may not recur.

Alfred Mauro is director emeritus of Jersey City Medical Center Anesthesia and Pain Management. He can be reached at almauro@optonline.net.