Clinical‐Radiologic Heterogeneity of Occipital Neuralgiform Pain as Multiple Sclerosis Relapse

Abstract

Occipital neuralgia may be related to traumatic, compressive, or inflammatory injury to the occipital nerve or C2 radicular level and cervical spinal cord lesions. We report a series of 3 patients with definite relapsing-remitting multiple sclerosis (MS) who experienced sudden occipital neuralgiform pain with or without diminished sensation in the cervical region and associated with magnetic resonance imaging (MRI) evidence of a new active or new T2-weighted demyelinating C2 cervical lesion. We suggest that sudden paroxysmal occipital pain may signal relapse of MS and cervical MRI with gadolinium should be considered; these patients show good clinical response to high-dose intravenous corticosteroids.

Pain in multiple sclerosis: A systematic review of neuroimaging studies

“…Spinal cord lesions corresponded to headache disorders in two studies (Alstadhaug et al, 2008; de Santi et al, 2009) (Table 5). Lesions including both the peripheral and the CNS were described in one study (brainstem and trigeminal nerve — Pichiecchio et al, 2007).…”

“…1). Thirty-eight met the inclusion criteria (Alstadhaug et al, 2008; Andrade et al, 2012; Athanasiou et al, 2005; Balasa and Bajko, 2010; Bentley et al, 2002; Broggi et al, 2004; Burkey and Abla-Yao, 2010; Carrieri et al, 2009; Cordella et al, 2009; Cruccu et al, 2009; da Silva et al, 2005; Davey and Al-Din, 2004; Deppe et al, 2013; de Santi et al, 2009; Donat, 2012; Eldridge et al, 2003; Fragoso and Brooks, 2007; Gass et al, 1997; Gee et al, 2005; Gentile et al, 2007; González-Quintanilla et al, 2012; Haas et al, 1993; Hellwig et al, 2006; Kister et al, 2010; Leandri et al, 1999; Liu et al, 2008; Marchettini et al, 2006; Meaney et al, 1995; Minagar and Sheremata, 2000; Nakashima et al, 2001; Pichiecchio et al, 2007; Ramirez-Lassepas et al, 1992; Svendsen et al, 2011; Tanei et al, 2010; Tortorella et al, 2006; Tosi et al, 1998; Vilisaar and Constantinescu, 2006; Yetimalar et al, 2008). Of these, 16 were case reports (Alstadhaug et al, 2008; Andrade et al, 2012; Bentley et al, 2002; Burkey and Abla-Yao, 2010; Carrieri et al, 2009; Davey and Al-Din, 2004; Donat, 2012; Gentile et al, 2007; González-Quintanilla et al, 2012; Haas et al, 1993; Leandri et al, 1999; Liu et al, 2008; Pichiecchio et al, 2007; Tanei et al, 2010; Tosi et al, 1998; Vilisaar and Constantinescu, 2006), nine were case series (Athanasiou et al, 2005; Cordella et al, 2009; de Santi et al, 2009; Fragoso and Brooks, 2007; Hellwig et al, 2006; Marchettini et al, 2006; Meaney et al, 1995; Minagar and Sheremata, 2000; Nakashima et al, 2001), and 13 were investigational studies (<...>…”

“…The type of MS in subjects was not fully described in 14 studies (Athanasiou et al, 2005; Balasa and Bajko 2010; Burkey and Abla-Yao, 2010; Cruccu et al, 2009; Donat, 2012; Eldridge et al, 2003; Fragoso and Brooks, 2007; González-Quintanilla et al, 2012; Kister et al, 2010; Marchettini et al, 2006; Meaney et al, 1995; Minagar and Sheremata, 2000; Ramirez-Lassepas et al, 1992; Yetimalar et al, 2008). It was relapsing–remitting in 16 ((Alstadhaug et al, 2008; Andrade et al, 2012; Bentley et al, 2002; Carrieri et al, 2009; Deppe et al, 2013; de Santi et al, 2009; Gentile et al, 2007; Haas et al, 1993; Hellwig et al, 2006; Leandri et al, 1999; Liu et al, 2008; Nakashima et al, 2001; Pichiecchio et al, 2007; Tanei et al, 2010; Tosi et al, 1998) (Minagar and Sheremata, 2000) – one case). Six studies included patients with various MS subtypes (Broggi et al, 2004; da Silva et al, 2005; Gass et al, 1997; Gee et al, 2005; Svendsen et al, 2011; Tortorella et al, 2006).…”

“…Lesions were identified in the CNS ( i.e. central neuropathic pain) in 21 studies; of these, lesions were located in the spinal cord in six studies ((Alstadhaug et al, 2008; Burkey and Abla-Yao, 2010; Tosi et al, 1998) (de Santi et al, 2009) — three cases (Hellwig et al, 2006) — four cases: only two documented with MRI (Marchettini et al, 2006) — five cases), in the brainstem in 13 studies ((Bentley et al, 2002; Donat, 2012; Gentile et al, 2007; González-Quintanilla et al, 2012; Haas et al, 1993; Leandri et al, 1999; Liu et al, 2008; Tanei et al, 2010) (Meaney et al, 1995; Nakashima et al, 2001; Vilisaar and Constantinescu, 2006) — one case (Fragoso and Brooks, 2007) — two cases (Cordella et al, 2009) — five cases), in the thalamus in one study (Deppe et al, 2013) and in multiple locations throughout the pyramidal tract in another study (Andrade et al, 2012). …”

“…This emphasis is at odds with estimates of prevalence of pain syndromes in MS — for example TN is reported in 1–5% of MS patients, as compared to an overall pain prevalence of approximately 50% (Polman et al, 2011). Other cranial pain syndromes examined in included studies (such as occipital or glossopharyngeal neuralgia (Carrieri et al, 2009; de Santi et al, 2009; Minagar and Sheremata, 2000; Vilisaar and Constantinescu, 2006)) are even less common. These observations could suggest that studies identifying neuroradiological correlates of neuropathic pain syndromes in general, and headache or facial pain syndromes in particular, are disproportionately represented by the current literature (Bax and Moons, 2011).…”