A Letter Released to Physicians on November 7, 2006

Providing Advanced Treatments for
Recalcitrant Headaches

Every year, 17% of women and 14% of men present themselves to a primary care practitioner looking for relief from headaches.¹ Unfortunately, more than five percent of the adult population experiences recurring headaches that do not respond satisfactorily to conventional care.^2,3 Effects can range from poorer quality of life, to impairment, to disability.⁴ In these cases, please consider a referral to Neal S. Taub, MD, Physiatrist for specialized pain medicine. The private practice of Dr. Taub makes a number of specialized services and treatments available to your patients suffering from chronic headaches: trigger point injections, occipital nerve blocks, chemical neurolysis, medical acupuncture, therapy supervision, analgesic consultation & monitoring, pre-surgical second opinions, etc. Here, we review three of the specialized treatments that often provide rapid relief for chronic headaches.

Muscle Injections:

While cervicogenic elements contributing to chronic headaches may sometimes go unaddressed in initial treatment plans, studies suggest that as many as 35% of medically treated headaches are cervicogenic in nature.⁵ Various reports have demonstrated that muscular lesions of the cervical spine and/or shoulder (i.e. trigger points, spasm, hypertonicity) can result in referred pain subjectively experienced in the anterior or posterior cranial muscles.^6-12 While there are many methods for addressing trigger points, injection has been shown to be one of the most efficient and effective modalities for prompt relief of symptoms.¹³ When the muscular dysfunction contributing to recurring headaches is more diffuse than trigger points (i.e. spasm, hypertonicity), botox injections into problematic muscles may prove helpful in breaking the pain cycle.^14,15

Occipital Nerve Blocks:

Occipital nerve blocks are injections of anesthesia, sometimes in conjunction with a steroid, into peripheral nerves at the back of the neck. This treatment blocks pain impulses from damaged structures and potentially reduces inflammation. Because the injections are relatively superficial and locally acting, side effects are rare when performed correctly.

The occipital nerve may participate in many types of headaches. One common presentation that indicates occipital nerve involvement is the experience of pain that starts at the back of the head and then spreads toward the forehead. Of course, occipital neuralgia suggests the use of occipital nerve blocks. Clinically, occipital neuralgia usually presents as a pain in the dermatomal distribution of an occipital nerve. In 2/3 of cases, pain is unilateral.¹⁶ Patients typically describe the pain as lancing, electric, or shock-like. Nerve block injections can be both diagnostic and therapeutic. Repeated blocks can provide permanent relief,¹⁷ or indicate that an ablation or neurolysis would probably provide permanent relief.

Chemical Neurolysis (Phenol or Botox):

This injection treatment results in the destruction or dissolution of nerve tissue, typically a dorsal root ganglion. Pain relief effects can be temporary or permanent. Chemical neurolysis can serve as a preferable alternative to surgical ablation.

Please refer your patients to Neal S. Taub, MD, Physiatrist

References

1. Clinch C R. “Evaluation of Headaches in Adults.” American Family Physician: Feb 15, 2001; 63 (4): 685-697.
   
2. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache 1998;38:497-506.
   
3. Castillo J, Munoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache 1999;39:190-6.
   
4. Lord SM, Barnsley L, Wallis BJ, et al. “Third occipital nerve headache: a prevalence study.” J Neurol, Neurosurg Psychiatry 1994; 57: 1187-1190.
   
5. Anthony N. “The prevalence of cervicogenic headache in a random population sample of 20-59 year olds.” Spine 1995; 20: 1884-1888.
   
6. Kidd RF. Nelson R. “Musculoskeletal dysfunction of the neck in migraine and tension headache.” Headache. 1993;33:566-569
   
7. Pfaffenrath V, Dandekar R, Pollmann W. “Cervicogenic headache – the clinical picture, radiological findings and hypotheses on its pathophysiology.” Headache. 1987;27:495-499.
   
8. Solomon S, Lipton RB, Newman LC. “Nuchal features of cluster headache.” Headache. 1990;30:347-349.
   
9. Watson DH, Trott PH. “Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance.” Cephalalgia. 1993; 13:272-284.
   
10. Meloche JP, Bergeron Y, Bellavance A. et al. “Painful intervertebral dysfunction: Robert Maigne’s original contribution to headache of cervical origin.” Headache. 1993;33:328-334.
    
11. Olsen J. “Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs.” Pain. 1991;46:125-132.
    
12. Jaeger B. “Are cervicogenic headaches due to myofascial pain and cervical spine dysfunction?” Cephalalgia. 1989;9:157-164.
    
13. Alvarez D. “Trigger points: Diagnosis and Management.” Am Fam Physician 2002; 65: 653-60.
    
14. Wheeler A. “Botulinum toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension.” Headache, 1998 Jun, 38(6), 468-71.
    
15. Domzal T. “Botulinum toxin in the treatment of pain.” Neurol Neurochir Pol, 1998, 32 Suppl 1, 57-60.
    
16. Lozano AM, Vanderlinden G, Bachoo R, et al. “Microsurgical C-2 ganglionectomy for chronic intractable occipital pain.” J Neurosurg 89: 359-365, 1998.
    
17. Wang M, et al. “Ganglionectomy of C-2 for the treatment of medically refractory occipital neuralgia.” Neurosurg Focus 2002: 12 (1).