Posted at 22:17h
By Robert Kunkel, MD, Consultant, Center for Headache and Pain Neurological Institute, Cleveland Clinic, Cleveland, OH
in Case Study
I first saw George on March 12, 2008. He was 75 years old and had had a headache since December 12, 2007, when he slipped on ice and fell. He said he didn’t hit his head, but he had left-sided neck and head discomfort afterward, which had persisted. He had high blood pressure, which was well controlled, but no other significant medical problems.
George described the head pain as “sharp” and constant in character. It was strictly on the left side and involved the left neck and upper shoulder area, the back of the head and spread forward above the left ear into the temple. It was not aggravated by neck motion, coughing or straining. He had a CT scan of the brain in January of 2008, which was negative, and a CT scan of his neck showed only mild degenerative arthritic changes. He was referred for physical therapy, which helped the neck pain but had no effect on his headache.
In February, his primary care physician diagnosed him with occipital neuritis and he was put on a dose of prednisone (a cortisone) that was tapered over the course of seven days. His head pain was completely gone for a few days but recurred when he reduced the dose. In addition to the head discomfort, George reported that he felt tired and had a lack of stamina. While taking the prednisone, he “felt like a new man.”
When I examined him, he had been off of prednisone for over two weeks. The exam was normal, including his blood pressure, except for mild tenderness with pressure over the left lower neck and at the base of the skull. His neck motion was slightly reduced.
On the presumption that this was a form of occipital neuralgia, we injected his occipital nerve with a mixture of an injectable cortisone preparation and a local anesthetic. Following this procedure, he was free of pain for five days.
Because this was a new headache for George, and because of his response to the prednisone, the diagnosis of temporal arteritis was also considered. On lab testing, he had an elevated sedimentation rate (sed rate), which reflects inflammation in the body. His sed rate was 70 while a normal level is between 0 and 20. Because of this elevated sed rate, we had a biopsy of the left temporal artery done one week after his first visit. His headache had returned by then and the biopsy showed active inflammation in the artery wall, which is typical of temporal arteritis. He was started on a daily dose of 60 mg. of prednisone along with extra calcium and vitamin D.