Case Report
Rapid Relief of Acute Posttraumatic Headache and Face Pain with Lower Cervical Spine Paravertebral Intramuscular Injections
Gary A Mellick1* and Larry B Mellick2
11Department of Neurology, DeKalb Regional Medical Center, USA
2Department of Pediatrics, DeKalb Regional Medical Center, USA
*Corresponding author: Gary Mellick, Department of Neurology, DeKalb Neurology and Sleep, DeKalb Regional Medical Center, Fort Payne, AL, USA
Published: 14 Sep, 2016
Cite this article as: Mellick GA, Mellick LB. Rapid Relief
of Acute Posttraumatic Headache and
Face Pain with Lower Cervical Spine
Paravertebral Intramuscular Injections.
Ann Clin Case Rep. 2016; 1: 1132.
Abstract
Background: Treatment of headaches and facial pain with lower cervical injections has been reported previously but such treatment of acute posttraumatic headaches has not previously been reported.
Aims: Describe the lower cervical paravertebral injection technique and report the efficacy of the
injections in a series of patients with acute posttraumatic headaches.
Methods: In a series of patients with recent head injuries and resultant acute posttraumatic
headache, local anesthetic was injected intramuscularly into the lower cervical region approximately
2 inches lateral to the seventh cervical vertebral process.
Results: In this series of patients, there was rapid headache relief with resolution of the headache
pain as well as accompanying facial and dental pain.
Conclusions: The results are indicative that lower cervical intramuscular local anesthetic injections
may be an effective therapeutic modality to treat acute posttraumatic headaches.
Keywords: Posttraumatic headache; Head trauma; Cervical injections; Trigeminovascular system; Cephalgia; Pain; Traumatic brain injury
Introduction
Posttraumatic headache (PTH) ascribed to head injury is defined as a secondary headache
according to the International Classification of Headache Disorders, 3rd edition (beta version)
(ICHD-3 beta) [1]. The criteria for acute posttraumatic headache (APTH) require that the headache
begins within 7 days after the head injury and resolves within 3 months of the head injury [1].
Recent media attention on concussion and sports related injuries [2-4] and head injuries as a
result of the Iraq and Afghanistan military conflicts5 has greatly increased public awareness of
posttraumatic headache since it is the most common symptom that results from head injury [6,7].
Acute posttraumatic headache (APTH) is the most frequent finding after closed head injury in the
US military [8] and headache is the most constant symptom following concussion occurring in more
than 90 % of athletes with sports-related concussion [9]. The prevalence of chronic daily headache
(CDH) in returning U.S. soldiers after a deployment-related concussion is 20%, or 4- to 5-fold
higher than that seen in the overall U.S. population [10]. Despite an incidence of approximately 3.8
million sports-related concussions per year, the pathophysiological basis of this injury continues to
be poorly understood [11]. APTH has remained a distinct treatment challenge for medical personnel
and as a result, it is often inadequately controlled [12]. APTH frequently confounds deployment or
return to play decisions [11]. The treatment of PTH is largely empiric. To date, no randomized,
blinded, prospective, class I medication treatment trials of PTH have been conducted [12].
This is the first case series reporting the use of the lower cervical intramuscular bupivacaine
injection in the treatment of acute posttraumatic headache. The lower cervical injection for the
treatment of headache and orofacial pain has been previously reported [13-16]. The lower cervical
paraspinous injection is similar to a typical intramuscular trigger point injection and is performed
as follows. A syringe is filled with 3 or 4 cc of 0.5% bupivacaine HCL. The lower dorsal cervical spine
is sterilely prepped by swabbing with an antiseptic solution and then with the patient sitting in front of the clinician with their head held upright in a relaxed, neutral
position, the medication is slowly guided into untensed musculature
2 to 3 cm lateral to the C6 or C7 vertebral spinous process along
an axis horizontal to the floor (Figure 1). The needle should be
inserted approximately one inch into the paravertebral musculature
perpendicular to or with a small upward angulation to the transverse
plane of the lower dorsal neck on both sides of the spine. As with any
injection procedure careful identification of anatomical landmarks,
aspiration before injection, and appropriate precautions should be
taken to manage the potential of vasodepressor syncope.
Case Presentation
Case 1: A 17 year old female driving her mother’s truck at 50 mph
bent down to pick up something off the floor and crashed into back
of a stopped car. She reported hitting her head against the steering
wheel as well as hitting her anterior left leg against another part of
the truck. No airbags deployed. However, the front of the truck was
severely crushed and windows were shattered. She experienced no
loss of consciousness. She reported that her headache was diffuse
and 8 out of 10 in severity. She also reported forehead soreness where
her head struck the steering wheel. Her neurologic examination was
non-focal and normal. Minimal edema and erythema was noted of
the forehead. After discussing imaging options and risks with the
patient’s mother a decision was made to not obtain a CT scan and to
observe the patient for a period of time in the emergency department.
Paraspinous cervical injections with bupivacaine were offered
to the patient for management of her post traumatic headache. The
cervical injections resulted in complete headache relief rapidly and
within 5 to 10 minutes. The patient was subsequently discharged
home headache free after a period of observation in the emergency
department.
Case 2: While visiting a friend, a 23-year-old male attempted to
sit on a nine-foot high horizontal metal bar. When he jumped on to
the bar, he fell backwards and landed headfirst on a cement patio.
He immediately experienced a brief loss of consciousness. During the
subsequent ED evaluation he received sutures for a scalp laceration,
cervical spine x-rays and a head CT scan that showed no intracranial
pathology. In addition to local neck and head pain at the site of
impact, he complained of a severe, generalized unrelenting headache
that was resistant to treatment with NSAIDS, isometheptene and acetaminophen with codeine. This headache persisted for 3 weeks
following the injury. The headache intensity was always above 6/10 on
a verbal pain scale and was associated with photophobia and blurred
vision. On presentation to a private pain practice the examination was
significant only for dorsal scalp allodynia and occipital hyperalgesia.
When the lower cervical paravertebral injections were completed the
patient reported that he felt a heavy, warm sensation travel up the
back of his neck. His headache disappeared completely in less than
3 minutes. The dorsal scalp allodynia and hyperalgesia were also
completely relieved, as was the associated photophobia. When seen
two weeks later, the patient reported that his headache following the
injection was never more than 1-2/10 in severity. A second injection
was completed with complete relief of the headache. Approximately
two weeks later the patient reported a return of his headache after
bicycling and vigorous exercise. Following a lower cervical injection
the patient’s headache again completely resolved along with
associated symptoms.
Case 3: Five days prior to evaluation this 21 year-old male was
struck in the left temporal area by a pitched softball. A continuous
headache developed following the head injury. His examination
was significant for mechanical hyperalgesia over the impact region.
Headache severity was rated at 7/10. Bilateral lower cervical
intramuscular injection with bupivacaine and solumedrol resulted in
rapid and complete headache relief. Additionally, the hyperalgesia of
the contusion area was also relieved. When re-evaluated 3 weeks later,
the patient related that his headache had not returned. Temporal
scalp pain was 1-2/10 in severity for two additional days before the
pain completely resolved. On subsequent visits, the patient reported
that his headache never returned.
Case 4: A 22-year-old white male sustained a head injury and
orofacial trauma after colliding with a friend while roller blade
skating. A brief loss of consciousness occurred. Additionally, there
was avulsion and subsequent reimplantation of the right maxillary
central incisor as well as extrusive luxation of the mandibular
central incisors. Since the accident the patient had experienced ongoing
severe right maxillary dental pain with hypersensitivity to
cold water and light touch. He also experienced significant dental
and gingival pain in the luxated but stabilized teeth. His pain was
unresponsive to hydrocodone with acetaminophen or oxycodone
with acetaminophen. In addition, the patient reported a constant,
throbbing, posterior headache rated at 7–10/10 in severity. A C6-
C7 paraspinous intramuscular bupivacaine injection was performed
bilaterally. Not only was the patient’s headache relieved, his dental
pain was reduced to 1/10 in severity. Subsequent to the injection, the
patient was able to bite down, drink tap water, and run cold water
over his previously painful teeth. In follow-up, the patient reported
that his dental pain remained diminished and that the headache had
not returned.
Case 5: This 20 year-old male was assaulted at a local service
station with resultant multiple face contusions. When he presented
to the clinic one day after the injuries, he complained of continuous
headache, severe facial pain and sleep disruption. His examination
showed extensive ecchymoses and abrasions. The neurologic
examination was unremarkable. Palpatory examination of the left
orbital wall revealed crepitus and mechanical hyperalgesia over
and around areas of facial injury as well as over his posterior scalp
where he had fallen striking the back of his head with brief loss of
consciousness. A subsequent facial CT scan showed an orbital wall fracture and he was referred for ophthalmology specialty care.
Treatment options were discussed with the patient and he elected to
have a bilateral C6-C7 bupivacaine injection. The injection resulted in
complete relief of the headache and facial pain. Examination after the
injection showed complete relief of mechanical hyperalgesia of the
head and face. He denied having further headache.
Case 6: A 21-year-old female United States Air Force security
personnel presented with frequent and severe left sided posttraumatic
migraine type that began approximately three weeks prior to
evaluation when an M16 rifle fell seven feet from where it was hanging
striking her in the region of the left temple. Since the event the patient
had been experiencing a severe throbbing generalized headache
and neuropathic allodynia at the site of weapon impact that was
exquisitely tender to palpation. The first author discussed treatment
options including bilateral lower cervical bupivacaine injections.
When this procedure was eventually completed, she described rapid
and complete headache relief. In addition, when the right temple was
palpated, she described greatly diminished allodynia and hyperalgesia.
When the patient returned for a subsequent visit, she reported that
she had remained headache free for three days. She subsequently
underwent a series of further lower cervical paravertebral injections
but unfortunately the headaches and allodynia would return. A
regimen of gabapentin 600 mg qid, 50 mg of amitriptyline qhs and
duloxetine 300 mg po BID managed to reduce frequency and severity
of her headaches as well as reduce the associated posttraumatic
neuropathic pain.
Case 7: A 32-year-old Hispanic male sustained a brief loss of
consciousness, head trauma and facial lacerations after flipping
a 4-wheeler while camping. When he regained consciousness, he
described an intense throbbing, generalized headache. A head CT
and brain MRI were both negative for brain injury and cervical spine
x-rays were normal. The facial lacerations were sutured and he was
prescribed gabapentin 300 mg po qid and hydrocodone 7.5 mg po
tid for pain and released. One week later, when seen for a neurology
consultation, the patient complained of ongoing severe headache.
Options of therapy were given and the patient opted to have a bilateral
C6-C7 cervical intramuscular injection. When this was completed
using 1.5 cc bupivacaine bilaterally, the patient experienced rapid
headache resolution. He also reported a reduction in his residual
facial pain which dropped from 5/10 to 1/10 in severity. At his one
month follow up, he reported that the headache had never returned
and his residual facial pain was of a lower intensity.
Case 8: A 19-year-old male presented with a severe (10/10),
generalized headache one day after a head-on motor vehicle crash
associated with a brief loss of consciousness. His work-up in a local
emergency department consisted of brain imaging and cervical
radiographs. His radiological studies and neurologic evaluation
were normal. Palpation of the occiput and upper neck was painful.
The patient elected to have the bilateral C6-C7 level intramuscular
bupivacaine injections. The injections resulted in headache relief that
occurred in less than one minute. Furthermore, the palpable occipital
and upper neck tenderness were also relieved. When reevaluated one
month and one year later, the patient reported that the headache had
never returned.
Figure 1
Discussion
The mechanism of development of the APTH continues to be
poorly understood. Multiple events and nociceptive stimuli activate the trigeminovascular system, the final common pathway to a
spectrum of headache presentations. Other headache classifications
as well as migraine headaches and their associated signs and
symptoms have been attributed to activation of the trigeminovascular
system and the subsequent release of vasoactive neuropeptides [17-
19]. Vasoactive neuropeptides such as calcitonin gene-related peptide
(CGRP), substance P, and neurokinin A are released from trigeminal
nerve terminals and these induce cranial vessel dilatation and
inflammatory reactions in meningeal blood vessels. Vasodilatation,
plasma protein extravasation, neurogenic inflammation and
activation of trigeminovascular afferents are the end result [17,20,21].
Recent research by Tali Benromanoa, et al. [22] shows that mild closed
head injury in mice is coupled with a selective enhancement of deep
cranial trigeminal nociceptive processing. They found that mild head
injury caused a rapid bilateral acute degranulation of periosteal mast
cells which they believe leads to increased cranial nociception due
to enhanced sensitivity of the trigeminal nociceptive system where
the trigeminal ganglion holds the cell bodies of nociceptive fibers
that innervate the calvarial periosteum and deeper cranial tissues
where these fibers synapse centrally on neurons in the trigeminal
nucleus caudalis which is part of the brainstem dorsal horn or what
some call the trigeminal brainstem sensory nuclear complex [22].
In their opinion, this pro-inflammatory response within the cranial
periosteum results in the APTH and that augmented pain processing
by supraspinal nociceptive pathways does not appear to play a major
role in mediating the resultant acute trigeminal hypernociception
seen following head trauma.
The mechanism of pain relief following injection of anesthetic
into the lower paravertebral cervical spine is unknown. One possible
explanation is that pain relief may be related to the convergence
of the trigeminal nerve with sensory fibers from the upper cervical
roots at the trigeminal nucleus caudalis. It is also possible that these
injections are interrupting afferents that are involved somehow in
sustaining or possibly generating the headache and activating the
trigeminovascular system. It may involve an inhibitory neuronal
network that descends from the frontal cortex and hypothalamus
through the periaqueductal gray to the rostral ventromedial medulla
to the medullary and spinal dorsal horn. These cells are known to
modulate the activity of the trigeminal nucleus caudalis and dorsal
horn neurons [23-25].
Whatever the mechanism of pain relief, the apparent “soft reboot”
process results in complete headache resolution along with relief of
all associated signs and symptoms including centrally mediated scalp
allodynia, [26,27] nausea, vomiting, photophobia, and phonophobia
found with migraines headaches. The response is robust resulting in
resolution of acute posttraumatic headache and orofacial pain within
minutes.
In conclusion, our experience suggests that acute posttraumatic
headaches are especially responsive to paraspinous injections with
0.5% bupivacaine. In this article we present a representative case
series of patients presenting with acute posttraumatic headache who
experienced rapid relief of headache and associated orofacial pain
following intramuscular injection of 0.5% bupivacaine bilateral to the
spinous process of a lower cervical vertebrae. A better understanding
of the physiology behind the pain relief associated with this
injection technique will provide greater insight into the genesis and
pathophysiology of acute posttraumatic headache and other IHS
categories of headaches.
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