Torbjørn A Fredriksen

Neurolysis of the Greater Occipital Nerve in Cervicogenic Headache. A Follow Up Study

SYNOPSIS

“Cervicogenic Headache”: Clinical Manifestation

The main criteria of “cervicogenic headache” are considered to be as follows: relatively rare and long-lasting unilateral attacks of severe headache, although seemingly of a non-excruciating character, signs of neck involvement, and lack of “cluster pattern”. In the present communication, the clinical manifestations in 11 patients fulfilling these criteria are described. All 11 patients selected in accordance with these criteria proved to be females, the age at onset ranging from 6 to 40 years (mean, 30 years). The mean duration of symptoms was 13 years. Six patients had had previous head/neck injuries. All patients had pain periorbitally, in the temporal region, and in the low occipital region (nape of the neck); less frequent were frontal, parietal, and facial pain and pain in the upper part of the occipital region. The duration of attacks was from 3 h to 3 weeks, and the interval between attacks lasted from 2 days to 2 months. The commonest accompanying phenomena were phonophobia, dizziness, ipsilateral eyelid edema, ipsilaterally blurred vision, and irritability. Some of the patients also had nausea (n = 7) and vomiting (n = 6). On physical examination, slight to moderate reduction of movements in the neck was noted, and five patients had ipsilaterally reduced sensation for touch in the trigeminal area. All the patients except one were severely afflicted. Attacks could, in addition to occurring spontaneously, be precipitated in all patients by head movements or by pressure at specific points in the neck.

CPH and Hemicrania Continua: Requirements of High Indomethacin Dosages ‐An Ominous Sign?

Two female patients, one with chronic paroxysmal hemi‐crania and one with hemicrania continua, had a continuously high requirement of indomethacin, ie, 3 225 mg per day, for 4 and 7 years, respectively. In the hemicrania continua patient, a right (symptomatic side) C7 root affection due to disc herniation was demonstrated. Removal of the disc relieved the arm pain completely, and reduced the head pain and indomethacin requirement considerably initially. The other patient suffered from the unremitting form of chronic paroxysmal hemicrania with right‐sided attacks from the age of 16. Indomethacin, 200 to 250 mg per day generally kept the headache at bay, but during exacerbations, especially during menstrual periods, the dosage transitorily had to be increased to 250 to 350 mg per day. ACT scan with contrast at aged 18 (1987) was negative. In 1992, she started having new symptoms, including numbness on the ipsilateral side of the face and arm and difficulty swallowing. An MR scan showed a meningioma originating in the roof of the cavernous sinus on the symptomatic side. The meningioma was surgically removed. The postoperative indomethacin requirement was reduced, but only transiently. Patients with chronic paroxysmal hemicrania (CPH) and hemicrania continua (HC) with a continuously high indomethacin requirement may have grave additional disorders and should consequently be followed closely.

Cervicogenic headache. Radiological investigations concerning head/neck

Eleven patients with cervicogenic headache took part in a radiological diagnostic workup related to the head and neck. All the patients were female with a mean age of 43 years (range 25–59) at the onset of the study. Cerebral and cervical computer tomography as well as standard X-ray of the spine were carried out in all patients. Six patients underwent cerebral angiography and six cervical myelography. The different investigations showed no typical characteristic pathology in the group. No indication of a common therapeutic approach in this group of patients could therefore be derived from these investigations.

Cluster headache pathogenesis: A pupillometric study

Thirty-two cluster headache patients and healthy controls (n = 16-20 for the various tests) were examined by means of a Whitaker pupillometer during pain-free intervals. Eye drops of the sympathomimetic agents tyramine, hydroxyamphetamine, and phenylephrine were instilled into the conjuctival sacs on separate occasions, and pupillary diameters recorded at standard time intervals. The mydriatic responses of the two pupils were compared. A moderate, but statistically significant, basal relative miosis was found on the pain side in cluster headache. The symptomatic-side pupils were less responsive than their counterparts when stimulated with tyramine and hydroxyamphetamine, the difference being statistically significant for the OH-amphetamine test. With the phenylephrine test, however, the mydriasis on the symptomatic side significantly exceeded that of the contralateral pupil. This pattern of reactions does not quite correspond to those of “ordinary” Horner‘s syndrome (1st, 2nd, and 3rd neuron lesion). There are, however, gross similarities with the recently reported pattern in central sympathetic neuron dysfunction. In cluster headache there is probably a “Homer-like picture” rather than a proper Horners syndrome.

Sweat gland and pupillary responsiveness in Horner's syndrome.

Eight patients with Horners syndrome (five with a 1st neuron lesion and three with a 2nd neuron lesion) were examined for their pupillary responses to pharmacologic stimulation with tyramine (2%) and with phenylephrine (1%) eye drops. The same patients were also evaluated for their forehead sweating pattern on stimulation with body heating and pilocarpine injection, using the Evaporimeter. Five patients had a brain stem (1st sympathetic neuron) lesion, while three patients had had a traumatic C8-Th1 root avulsion and hence had a preganglionic neuron lesion. The average response with the phenylephrine eye test and the pilocarpine sweat test differed markedly between the two groups; only the central neuron lesion group had a supersensitivity reaction to both drugs. These procedures may be of diagnostic value in localizing the lesion in patients with a Horners syndrome of unknown etiology. Patients with 3rd neuron lesion have not been examined with this combination of techniques.

Cervicogenic headache: long-term postoperative follow-up.

The patient, a 50-year old female had been suffering from right-sided head- and neck pain since she was 31 years of age. It started in connection with an indirect neck trauma. Analgesics were of little or no avail and operative procedures, including liberation of the greater occipital nerve (GON) (n = 2) and decompression of the C2 ganglion/root, had only a transitory effect. At 42, a magnetic resonance scan of the cervical spine demonstrated a degenerated disk C5–C6, with encroachment on the foramina and the cord. At 42 years of age, a stabilization operation at C5–C6 (Robinson-Smith) alleviated her discomfort—only some motor complaints in the ipsilateral upper extremity remaining and only in the first 12–18 months.

Unilaterality of headache in classic migraine.

The localization of a headache is a matter of importance for the diagnosis. Migraine is considered to be a unilateral headache. There is, however, only limited information available on the constancy of the unilaterality: how frequently is the pain locked to one side? This aspect is of importance in the differential diagnosis vs. cervicogenic headache, where the pain persistently seems to occur on the one side. In the present study, 31 cases (26F, 5M with a mean age of 40 years; range: 17–63) with a diagnosis of classic migraine were questioned with regard to laterality of headache at the first consultation. A unilaterality as such was present in 42%; unilaterality alternated with bilaterality in 42% of the cases; unilaterality in some form was therefore found in 84% of the cases. In classic migraine, unilaterality thus seems to outweigh bilaterality. In every case of unilaterality there was a sideshift. A side-locked unilaterality thus seems to be a rare phenomenon in classic migraine. These patients were followed-up after between 3 and 9 years; they then filled in a questionnaire (response rate: 81%). The consistency between the two sets of information in the responders was good. Only one case (possibly two) showed a side-locked unilaterality at the time of the questionnaire.

Hemicrania continua. An indomethacin responsive headache. II. Autonomic function studies.

Various autonomic parameters have been studied in two patients with “hemicrania continua”, a newly described unilateral headache which is aborted by indomethacin. Striking findings were made on pupillometry: In both patients, isocoria was present when untreated. Bilateral instillation of tyramine in the conjunctival sac resulted in a late appearing anisocoria, with the smaller pupil on the symptomatic side. Indomethacin medication corrected this anomaly. These findings add further evidence to our firm belief that “hemicrania continua” differs fundamentally from chronic paroxysmal hemicrania, where such pupillometric changes are not found. There thus seem to be at least two different types of hemicranias with an absolute indomethacin effect.

Grading of headache intensity. A proposal

Abstract Current severity (intensity) grading in headache is based upon a 4-grade category scale that includes the zero grade. For ordinary scientific and practical work, a low-sensitivity scale may suffice. However, in given instances, such grading may be insufficient; one might for instance need to know more exactly where the healthy state ends and where headache starts. This may in particular concern epidemiological studies and mass screening. The placement of the “divisory bar” will naturally have a clear impact on the prevalence of headaches, especially the mild ones such as tension-type headache. A 7-step scale is proposed with “excruciating headache” at the top (e.g. cluster headache and chronic paroxysmal hemicrania). Below the mild category of the IHS scale, two categories have been proposed: I, minimal unpleasantness, without any reduction of thriving and without procrastination; and II, discomfort/heaviness with reduction of thriving and procrastination. The bar for discriminating between the healthy state and a headache disorder with an impact upon social life should probably be put between categories I and II on the scale. In situations where increased sensitivity of intensity grading is desirable, such a scale may be useful. This scale has been extensively used during the Vågå study of headache epidemiology, where it has been easy to apply. Consistency tests showed acceptable reproducibility values.