Occipital neuroma triggered cluster headache responding to greater occipital nerve blockade

Abstract

6 , though they may provide limited relief in some cases; moreover, some patients become steroid-dependent and develop serious steroid-related adverse effects within months. CH is marked by its circadian rhythmicity. Episodic cluster periods start at the same time each year, occur at the same time each day and the duration of each CH is almost the same for every attack. These clinical features, along with the hormonal alterations documented in CH patients, suggest that the hypothalamus plays a role in the genesis of CH. PET studies by May et al. 7 , revealed hypothalamic activation during CH attacks, supporting the hypothesis of hypothalamic involvement. The concept of the hypothalamus acting as a CH generator has also been entertained 8 . However, not all CH patients present the same symptoms, nor do all respond to the same medications, which suggests that atypical or even non-hypothalamic forms of CH may exist. Although the cervico-occipital onset of CH is not contemplated by the International Headache Diagnostic Criteria II-version (IHDC -II), it is not uncommon to find patients with this painful symptomatology in clinical practice. Anatomical and clinical data suggest that the greater occipital nerve (GON) may trigger pain that has the typical cluster characteristics and is associated with the autonomic symptoms noted in CH. Sensory neurons in the trigeminocervical complex receive ipsilateral and contralateral input from the GON 9 . We describe an atypical cluster headache with trigeminal symptoms that improve after the blocked of the greater occipital nerve in one patient with occipital neuroma. caseA 37-year-old woman came to the Headache Unit in our Pain Center in December 2005. She had a positive past medical history for migraine without aura. In March 2005, two weeks after a neck soft tissue trauma, she started experiencing daily headache attacks without periodicity. Each attack lasted from 30 to 120 min and occurred in the afternoons or evenings, with an average frequency of four attacks per day. The pain, which was always unilateral (right-sided), invariably started in the right occipital region and subsequently spread to the right eye and frontal region (Figure). The pain was severe and squeezing in nature, and was associated with right-eye ptosis, unilateral right-sided lacrimation and rhinorrhea (Figure). The pain was not associated with nausea, vomiting or phono-photophobia. During the attacks the patient was restless, rocking her head and body while standing or sitting.Oxygen and sumatriptan (subcutaneous 6 mg) were inconstantly effective, while NSAIDs did not provide any pain relief. The patient reported that the most effective pain control mechanism prior to referral to our Headache Unit had been the application of digital pressure to the right occipital region of the neck during the attacks. Preventive monotherapies (verapamil, valproate and steroids) previously prescribed by other physicians had been ineffective.Both the general and neurological examinations were normal, apart from the ...

Neurostimulation in cluster headache: A review of current progress

“…Clinically CH patients respond differently to medication, GON block, surgery and now neurostimulation (10,102,103). Also, atypical cases of CH have been reported in which CH patients do not experience the clock-like regularity of headache attacks as well as the restlessness and agitation typically associated with the hypothalamus (104,105). CH pain and autonomic features, however, can also be caused by an entirely central mechanism independent of peripheral signals, proven by a patient having received complete surgical sectioning of the trigeminal root, but still experiencing CH attacks on the same side (106).…”

Trigeminal Nerve Sheath Tumor Presenting as a Cluster Headache

“…2 Standard of care may include neuroimaging in any first presentation of presumed cluster headache to rule out a lesional cause. 3 An excitatory trigeminocervical convergence mechanism to the GON may provide a mechanistic explanation to our patient's cluster-like headache originating in the ipsilateral occipital region. The occipital origin of the headache is atypical considering cluster headaches typically occur in orbital, supraorbital, or temporal distributions.…”

“…A case report of cluster-like headache responding to greater occipital nerve (GON) blockade in a patient with occipital neuroma indicates a possible input from the GON to the trigeminocervical complex. 3 An excitatory trigeminocervical convergence mechanism to the GON may provide a mechanistic explanation to our patient's cluster-like headache originating in the ipsilateral occipital region. There is limited literature on the efficacy of surgical management in lesional causes of cluster-like headaches, although in one report removal of lesions causing trigeminal autonomic cephalalgia-like presentations resulted in significant or complete resolution of headaches in 31 cases.…”

Headache Research and Medical Practice in Brazil: An Historical Overview

“…A number of the early articles on headache disorders were published by Farias da Silva and coworkers in the scientific journal Neurobiologia (Recife), which is one of the oldest journals in the area of neurology in Latin America, founded in 1943 by Ulysses Pernambucano. Another important journal containing articles on headache written by Brazilians is Arquivos de Neuropsiquiatria , which was founded in 1945 …”