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A Challenging Case
A 39-year-old woman presents with a 2-year history of facial pain, headaches, and neck pain. The patient has a history of attention-deficit/hyperactivity disorder and had been receiving stimulant medication since childhood.
During the last 2 years, she developed a tic that caused her neck and head to shake while awake. She reports that this causes her unrelenting pain. The patient has tried various antiinflammatories, muscle relaxants, and neuropathic pain medications. She is not interested in opiate therapy.
Physical exam is positive for involuntary head bobbing movements. Her cranial nerves are intact, and she has pain on flexion, extension, and rotation of her neck. She is otherwise neurologically intact. Magnetic resonance imaging reveals a C6/7 herniated disc.
She has undergone Botox injections and various medications for her tic disorder, which have offered minimal relief. She reports that her pain is in the occiput, supraorbital region, and maxillary regions of her face bilaterally. Her pain also radiates to the jaw and neck. Cervical epidural was not considered, as there were no radicular findings. The procedure also does not appear to be safe because of her constant neck movements. Trigger points injections in the neck gave temporary relief.
An occipital nerve block was performed and did relieve her occipital pain temporarily, on multiple occasions. She underwent subsequent radiofrequency lesioning of the occipital nerve and received 40% relief for >2 months. The supraorbital nerve block relieved her pain temporarily as well. She was requesting radiofrequency lesioning of the supraorbital nerves; however, because of fear of burning her skin, she opted not to undergo radiofrequency ablation in the supraorbital region. Instead, she requested cryotherapy with iovera°. This was performed, and the results were disappointing.
The patient has generalized facial complaints and on 1 occasion responded partially to a sphenopalatine ganglion block; however, this only lasted a few weeks. The patient was also given a stellate ganglion block for atypical facial pain, which also helped for a few weeks. However, the pain relief was on the face, below her eyes, and did not cover the rest of her head and neck.
Although we know what the issue is, the fact that the patient’s head does not stop shaking makes it hard to treat.
Next best diagnostic step
The utility of an electromyogram is questionable, as the patient does not have radicular complaints.
An electroencephalogram is not indicated, as there is no suspicion of seizure, only presence of a tic.
Blood work may yield signs of an infectious etiology or of an electrolyte imbalance, although pain appears to result from nonstop head movements.
