title: Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis?
abstract: The differential diagnosis of headache is often challenging, with significant clinical and socioeconomic consequences of incomplete or inaccurate diagnosis. Overlapping symptoms contribute to the diagnostic challenge. Four female patients, ages 26 to 69 with standing diagnoses of migraine, were evaluated and treated for complaints of chronic, severe headaches. All had obtained limited relief from migraine therapies. On physical examination, all had occipital nerve tenderness or positive Tinel sign over the occipital nerve. All responded well to occipital nerve blocks with local anesthetic, achieving complete or substantial pain relief lasting up to 2 months. We conclude that accurate diagnosis of occipital neuralgia or cervicogenic headache as contributing factors can lead to substantial headache relief through occipital nerve blocks in patients with coexisting or misdiagnosed migraine.
  
  
  CONCLUSIONS
  The pathophysiology of many types of chronic headaches is not well understood. Mixed mechanisms such as neurovascular, neuropathic, myofascial, and cervicogenic may all contribute. Our four patients with chronic headaches responded well to occipital nerve blocks. The neuroanatomical relationship between the trigeminocervical nucleus and occipital nerve may serve as the basis of efficacy for these blocks.
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA. yix@wustl.edu
authors.forename: Xiaobin
authors.initials: X
authors.lastname: Yi
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Cook
authors.forename: Robin J
authors.initials: RJ
authors.lastname: Hamill-Ruth
authors.forename: John C
authors.initials: JC
authors.lastname: Rowlingson
mesh_terms: D000328:Adult; D000368:Aged; D000779:Anesthetics, Local; D002045:Bupivacaine; D002572:Cervical Plexus / Q000187:drug effects / Q000503:physiopathology; D002574:Cervical Vertebrae / Q000503:physiopathology; D002908:Chronic Disease / Q000628:therapy; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control*; D005260:Female; D020773:Headache Disorders / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology; D006801:Humans; D008012:Lidocaine; D008875:Middle Aged; D008881:Migraine Disorders / Q000175:diagnosis* / Q000503:physiopathology; D009334:Neck Muscles / Q000503:physiopathology; D009407:Nerve Block / Q000379:methods*; D009437:Neuralgia / Q000175:diagnosis* / Q000503:physiopathology; D051298:Post-Traumatic Headache / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology; D013127:Spinal Nerves / Q000187:drug effects / Q000503:physiopathology; D016896:Treatment Outcome
chemical_list: D000779:Anesthetics, Local; D008012:Lidocaine; D002045:Bupivacaine