Author: Cornelia Atherton MD,
Assistant Professor, Department of Anesthesiology and Perioperative Medicine,
University of Louisville School of Medicine, USA.
Headache is the most prevalent pain disorder, affecting 66% of the global population.
The most common form of headache is tension-type headache with a global prevalence of 38%. Migraine has a prevalence of 10%, chronic daily headache 3%, and cervicogenic headache (CGH) 2.5–4.1%.Headache is a common postoperative complication reported by 10% to 38% of the patients during the first 24 hours after surgery, along with drowsiness, sore throat, muscle aches, vomiting (the most undesirable) and pain at surgical site.
Risk factors associated with postoperative headache mentioned are: caffeine intake, alcohol consumption, history of regular headaches, age < 51yrs, female sex, and dehydration.Increased frequencies of headache and alcohol consumption were found to be independent risk factors in a prospective, observational study.
Research from the Mayo Clinic showed that caffeine (a cerebral vasoconstrictor) given to patients intravenously during recovery after surgery can diminish or eliminate headaches caused by rebound vasodilatation from caffeine withdrawal.
We report here in a case of a severe, debilitating postoperative headache that had a complete resolution after a simple occipital nerve block.
The case of a 59-year-oldman who had an unusual severe and debilitating postoperative headache and its challenging management. The patient had undergone a routine general anesthetic through his permanent tracheal stoma for this 30 minutes procedure of direct laryngoscopy and esophagoscopy with esophageal dilation. Upon arrival at recovery room, patient complained of a severe, debilitating headache not responding to aggressive pharmacologic treatment, which resolved utilizing a novel treatment. Performing an occipital nerve block in the recovery room provided rapid and complete resolution of this condition, thus avoiding further escalation of additional medication with potential unnecessary side effects and further workup and consultations. We also offer a discussion of this condition and its treatment.
Herein, we review current literature from the fields of anesthesiology, neurology and otolaryngology. This case emphasizes the impact of patient positioning regardless of duration of the procedure. It stresses on the need for awareness among anesthesia providers of the patient’s preexisting neck pathology and its possible contribution to severe postoperative headaches, resistant to pharmacologic treatment. We discuss the role of the occipital nerve block as a simple therapeutic modality for resolution of this debilitating morbidity in the postoperative period.
The severity of this headache with sudden onset and resisting to medication administered raised the suspicion of intracerebral pathology and prompted surgeons to take him emergently for a CT scan of the brain, which ruled out a subarachnoid hemorrhage. While in CT, we learned from patient’s wife that three weeks earlier he was admitted to a community hospital for the first occurrence of a headache with same characteristics and intensity as the current one. He spent several days in ICU at that time with intractable headache for which he underwent extensive workup. Unfortunately, the patient did not mention the prior ICU stay for this problem during preoperative assessment.
Norwegian physician Ottar Sjaastad introduced the term, “cervicogenic headache” in 1983 by recognizing a sub-group of headache patients with concomitant head and neck pain. Cervicogenic headaches are considered “secondary headaches.”
Medical management usually begins with pharmacologic intervention; however, cervicogenic headache patients frequently do not respond to medications. Cervicogenic headache involves the posterior neck and head, it is predominantly, but not exclusively unilateral, has infrequent nausea and photophobia, the pain does not increase when bending forward, anti-migraine medications are not helpful and it is provoked by sustained, awkward neck position. Cervicogenic headache usually occurs without any demonstrable abnormality in cervical or brain imaging. More invasive procedures have been suggested in the literature such as occipital nerve blocks, anesthetic and steroid blocks and treatment with pulsed radiofrequency energy.
In our patient, we believe that the severe cervicogenic headache was triggered mechanically, by neck extension needed for this surgical procedure, with subsequent musculofascial compression and irritation of occipital nerves.Direct laryngoscopy and rigid esophagoscopy require neck manipulation and positioning of neck extension. Direct visualization of the pharyngo-laryngeal structures is known to cause considerable motion of the cervical spine in normal patients, primarily at the occipital-C2 segments and less so at C3 to C5 . Though the likelihood of spine misalignment and injury with laryngoscopy or procedures like rigid esophagoscopy seem to be low, the severe extension required for visualization of the structures combined with the muscle relaxation under general anesthesia occurs. This can be of concern in patients with preexisting spine pathology and may contribute to nerve irritation, and generated impulses from the stretched nerves may induce a headache.
Procedures involving severe neck extensions require our awareness and discussion with the patient of the possibility of postoperative head and neck pain. Preoperative history in regard of preexisting neck problems, trauma, arthritis, previous surgery, may place the patient under increased risk for postoperative headache and should be sought. There is limited evidence from controlled studies that peripheral nerve blocks seem to be viable treatment option for selected groups of headache patients, particularly those with intractable headache or facial pain. Further studies are needed to establish the efficacy of nerve blocks in intractable headache disorders. Challenges include the difficulty in creating valid designs and controlling for headache diagnosis excluding other confounding factors that might influence clinical improvement or lack of benefit. We present the occipital nerve block as a useful treatment for intractable headache in the indicated population in the postoperative setting.
This case report was published in International Journal of Anesthesiology & Research, SciDocPublishers.