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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 72 OF 100
A 39-year-old man has a 9-year history of headaches characterized by throbbing pain in the left occipital area. He reports having headaches at least 9 days a month during which time he experiences nausea but no light or noise sensitivity. Each episode lasts a few hours unless he takes ibuprofen at the onset of pain, which sometimes provides relief within 2 hours. He typically has to lie down or take off work for complete relief. The headaches seem to occur a few days in a row, but the patient cannot identify any particular trigger. Which of the following is the most likely diagnosis?
A. Cluster headache
B. Cervicogenic headache **
C. Occipital neuralgia
D. Paroxysmal hemicrania
E. Cervical radiculopathy
** = Your answer
The patient’s history and clinical presentation meets ICHD-3 beta criteria for cervicogenic headache, including evidence of causation demonstrated by at least two of the following findings:
* Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion
* Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
* Cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers
* Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply
One of the principal differential diagnoses of cervicogenic headache is migraine. Based on the patient’s history and clinical presentation, however, it would be difficult to rule out migraine. Cervicogenic headaches require facet injection to confirm the diagnosis, as described in ICHD-3 criteria. The patient’s diagnosis was confirmed in this way.
The location of the pain and lack of autonomic features or other characteristics of cluster headache ruled this out as a possible diagnosis. The patient’s pain pattern is not consistent with cervical radiculopathy or occipital neuralgia (i.e., paroxysmal pain with abrupt onset and termination, lasting up to 2 minutes).
Occipital neuralgia is not included in the differential diagnosis for cervicogenic headache, although in practice this type of pain often is labeled as occipital neuralgia based on location alone without any signs of neuralgia.
* Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808.
* 2. Sizer PS, Jr, Phelps V, Azevedo E, et al. : Diagnosis and management of cervicogenic headache. Pain Pract, 2005, 5: 255–274