Headache plus: trigeminal and autonomic features in a case of cervicogenic headache responsive to third occipital nerve radiofrequency ablation

OBJECTIVE: To describe a case of cervicogenic headache with associated autonomic features and pain in a trigeminal distribution, all of which responded to third occipital nerve radiofrequency ablation.

DESIGN: Single case report.

SETTING: Massachusetts General Hospital Center for Pain Medicine.

PATIENTS: A 38-year-old woman with history of migraines and motor vehicle accident.

INTERVENTIONS: Right third occipital nerve diagnostic blocks and radiofrequency lesioning.

OUTCOME MEASURES: Pain reduction; physical findings, including periorbital and mandibular facial swelling, tearing, conjunctival injection, and allodynia; and use of opioid and non-opioid pain medicines.

RESULTS: The patient had complete relief of her pain and autonomic symptoms, and was able to stop all pain medications following a dedicated third occipital nerve lesioning.

CONCLUSIONS: This case illustrates the diagnostic and therapeutic complexity of cervicogenic headache and the overlap with other headache types, including trigeminal autonomic cephalgias and migraine. It represents a unique proof of principle in that not only trigeminal nerve pain but also presumed neurogenic inflammation can be relieved by blockade of cervical nociceptive inputs. Further investigation into shared mechanisms of headache pathogenesis is warranted.