A harder case

[ghost dog]

Ok. Here's a tougher case.

I saw a 50 yr old pt in consult. He presented with a 4 month Hx of
constant left sided neck pain, and radiating headache located in the left occiput and left
retro-orbital region. He endorsed photophobia and phonophobia.

He also had experienced multiple episodes of melena.

He had attended the ER on 13 different occasions due to the severity of the pain, and been treated with IV opioids and ketoralac / toradol to minimal effect ( " no relief at all doc "). His family doc had attempted a TCA , gabapentin and Topiramate to no avail.

He had received a negative CT scan of the head and normal LP during his ER trips.

On exam in my office, he demonstrated decreased light touch over the left V1 and V2 dermatomes.

Any ideas in regards to Dx ?

What type of headache is this ?

What would your next step be here ?

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[deleted87716]

Sounds like trigeminal neuralgia. I'd suggest Tegretol, if he hasn't already tried it.

 

[rachmoninov3]

Type of headache: not thinking it fits into a typical headache (cluster, migraine, tension etc) given symptoms, timeline, and that fact that's its constant.

I'd wonder about some sort of physical encroachment around petrous bone/temporal lobe--any chance of something like paget's disease or a neuroma? Something subtle that wouldn't be found on CT...How about MRI?
No idea where the melena comes in...makes me worry for brain mets or one of the multiple tumor syndromes like Lynch's.

How about PMH, PSH, FH, SH, any other PE findings, and possibly an MRI?

 

[deleted87716]

No idea where the melena comes in

NSAID overuse, possibly.

A GI workup is in order, of course.

 

[ghost dog]

NSAID overuse, possibly.

A GI workup is in order, of course.

The type of headache was : cervicogenic.

This patient presented with neck pain radiating to the head. I believe this is where the ER docs missed the boat , so to speak, as they were looking for pathology in this region. He's got a headache after all !

The patient presented with multiple headache red flags, indicating that further work up is required:

1. Pain that begins suddenly, with peak onset within minutes.
2. Headache that is new or of different character for the patient ( particularly in pt > 50 ).
3. Headache that is progressive / worsening
4. Headache with fever
5. Headache with neuro signs.
6. Headache precipitated with a Valsalva maneveur.

This unfortunate gentleman turned out to have a nasopharnygeal cancer with metastatic disease to the cervical spine. Putting all the symptoms together, this makes sense. The primary cancer had eroded the GI tract, causing upper GI bleed. The bone mets in the cervical spine were causing cervicogenic headache ( referred pain ).

He subsequently saw me in follow up to tell me that that he had received a CT scan of the cervical spine identifying bone mets and NP cancer. His prognosis was palliative, and awaiting palliative rad Tx.

 

[ghost dog]

Sounds like trigeminal neuralgia. I'd suggest Tegretol, if he hasn't already tried it.

Patients with this condition will have severe, episodic pain lasting seconds to hrs in a distribution of the trigeminal nerve. The patient above had constant pain, and not in a trigeminal distribution.

Interesting practice tip: a male pt who presents with facial pain , and unshaven in a trigeminal distribution has trigeminal neuralgia until proven otherwise.

 

[deleted87716]

Weird. And the head CT didn't show anything? Weirder. Good case!

 

[ghost dog]

Weird. And the head CT didn't show anything? Weirder. Good case!

You peeps ask for a good case, you got it.

The above case also illustrates the "trigeminocervical relay" phenomenon, which is a fancy way of explaining referred head and neck pain:

1. If a patient has a structure in the upper cervical spine causing pain, they may perceive this as a headache - typically in the occiput or frontal region ( as can be seen with the above case).

2. Also, when a patient has a headache, they may experience neck pain. This can occur in patients with migraine.