Interesting case for me today and the first time I've seen this issue. 25 yom, thin, healthy, 6'3 200#. Referred by another pain management doc for cervical mb rfa. Neck pain for many years, axial; "burning" pain in axial neck, radiates from cervical area to occipital and frontal areas. He does have radiation from axial neck to supraspinous area to shoulder in C5-6 distribution with occasional muscle spasm. Pain is constant, but exacerbated by any type movement especially after long workday as lawn maintenance contractor. Pain level 5-9/10 varies with activity. Heat helps, PT no benefit. NSAID helping. Patient attributes onset of neck pain to working with horses and various falls while working, but no definitive injury. Neuro exam normal, non-focal. MRI shows small central osteophyte and focal disc protrusion with "borderline central canal stenosis," C7-T1 small right paracentral disc extrusion behind inferior endplate of C7 but no nerve root compression, small left T1-2 paracentral disc extrusion. Cervical Myelogram shows spur at T1-2 with symmetric filling of nerve root sleeves throughout cervical spine, a shallow right C7-T1 disc protusions without foraminal compromise; and left T1-2 disc/spur flattening the left anterior cord. The other pain doc has performed 3 cervical esi's at C7-T1 and C6-7 with benefit for 2-3 days each. He had right then left C3-4 and C4-5 facet injections with benefit for two weeks 60-70%. Bone scan Cspine normal. No RA, lupus, spondyloarthropathies in family, and patient's sed rate, ANA, HLAB27 normal. Positive rheumatoid factor at 17. Non-ttp over the GON and LON bilaterally without radiation. Ttp over the facets, positive facet load. Negative spurling's. Normal reflexes bue. Normal heel-toe, normal gait. Tender points throughout cervical musculature but no trigger points or spasm. Has h/o low back pain but I don't have the full history or imaging there. Patient warned me prior to procedure that he has severe HA following each cervical esi and facet injection. After the history, PE I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site. He had versed 2mg, fentanyl 100mcg, propofol. Then, postop (immediately upon awakening in PACU) he grabs frontal area and starts moaning before he can even communicate fully. Appeared to be legit, toxic-appearing. HA radiates from occipital to frontal area, "whole head." BP normal. Vitals normal. After boat load of opioids and phenergan, pain level improves to tolerable 5/10. I call the other surgery center where his previous blocks were performed and they confirm that after all the prior blocks he has had severe HA, and they have usually given morphine 20 mg, demerol 25 mg, dilaudid 1mg if necessary, 12.5 phenergan. Patient has had lumbar esi's, mbb's previously without significant headache postoperatively. I know this may be routine for some of you, but I haven't seen this previously. Any ideas regarding the headache? I asked all the usual questions about opioid abuse but patient appears to be legit, wife confirms everything. He takes lortab 7.5, one tablet daily after working all day. No tattoos, dresses well, pupils normal/reactive, no track marks.