Disclosures: Dylan W. Banks, MD: No financial relationships or conflicts of interest

Case Diagnosis: Cervicogenic headache

Case Description or Program Description: A female in her 60s presented with chronic headaches, facial pain, and tinnitus secondary to a motor vehicle accident 20 years ago. She additionally noted recently worsening neck pain. The pain was predominantly right suboccipital with additional pain along her right ear, jaw, and eye. Following the accident, she had been diagnosed with trigeminal neuralgia refractory to medications, therapies, trigger point injections as well as gamma knife intervention. On examination, we noted decreased cervical extension and lateral rotation and pain with cervical facet loading maneuvers. MR cervical spine was significant for multilevel facet joint arthrosis, disc bulges and moderate neural foraminal stenosis.

Setting: Outpatient pain clinic

Assessment/Results: The patient underwent two diagnostic third occipital nerve (TON), C3, C4 medial branch blocks followed by radiofrequency ablation (RFA). She reported over 90% relief of all symptoms and improved functional activity following RFA.

Discussion (relevance): C2-3 cervical facet arthropathy, innervated by the TON, was the inciting factor in the development of cervicogenic headaches and pain. Referred pain from the C2-3 zygapophysial joint, via the TON, can account for trigeminal symptoms as the cervical nerves communicate with the trigeminal nerves through the trigeminocervical nucleus. The prior treatment methods had failed as they did not address the root cause of her symptoms. Diagnostic TON and medial branch blocks are essential to diagnosing cervicogenic headaches. Previous publications indicate cervicogenic headaches are common after whiplash injuries, consistent with this case’s mechanism of injury.

Conclusions: Cervicogenic origin should be considered in the differential in cases of persistent facial pain with accompanying head or neck pain. Cervicogenic headaches can be particularly challenging to diagnose given their similarity in presentation to other headache disorders and craniofacial neuralgias. Medial branch and TON blocks are helpful in the diagnostic workup.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-misdiagnosed-case-of-cervicogenic-headache-a-case-report/