Option for cervical facet syndrome Tension headache

[KimSb]

I'm currently receiving PT and chiro for my chronic head pressure and forehead tightness due to diagnosed "Cervical facet syndrome." I was diagnosed by a Neuro MD at an academic hospital. I have constant tightness and pressure "tension headache" but no pain per se. Nothing has helped and in addition to the physical tight/pressure sensation, I have other debilitating Neuro symptoms from this condition that make me feel drunk or hungover.

I'm not having much success. The obligatory Elavil, triptans, Betas & Calcium blockers, and SSRIs had no effect, in fact made tit worse. My Neuro at a renown academic hospital wants to do left and right facet blocks and if helpful radio lesioning on the cervical facets. We may try Botox as well. We tried one block and the results were marginal, but not a huge difference.

Are these the ONLY modality for the Cervical facet & suboccipital nerve conditions? Naturally, I'm concerned about possible side effects of the lesioning procedure. If the facet blocks only show marginal improvement, is it dangerous to literally "fry" a nerve without knowing it will surely help?

[Joanna Fong, MD]

Hi KimSb,

From the description of your symptoms, you have chronic daily headache tension type.  Chronic daily headache can be caused by many different diseases.  Most commonly, neck pain/neck strain can trigger tension headache; in your case, the "cervical facet syndrome".  I do not know the nature of your cervical facet syndrome.  However, there are several things that you need to beware:  If you haven't had MRI cervical spine before, it's probably best to have it done to see if there's any nerve impingement or cord compression.  When you have nerve compression in the cervical cord region, you may experience pain, numbness, tingling sensation, and weakness in your arm.  A good neurological examination by a neurologist can identify those problems.  If there is nerve impingement, surgery may be indicated (neurosurgery consult).  

For treatment of chronic daily headache tension type:  infusion treatment with antiinflammatory (steroid, NSAID), DHE, depakote (seizure medications) may be useful.  You can get infusion treatment from headache centers in many big institutes (Cleveland Clinic has one).  You will need to see a headache specialist first before the infusion treatment.  This kind of infusion treatment will break the headache cycle.  Botox is another good option.  I would do the infusion treatment first.  I understand that you had botox once.  Your doctor will need to reevaluate to see if higher dosage of botox or different injection site is indicated.  You can also get botox injection in the headache centers that I mentioned above.

I would avoid overuse of over the counter nonsteroidal medications (advil, aleve, ibuprofen, motrin, etc).  This can sometimes cause "Rebound headache".  I would recommend to limit usage of those medications to less than 3 times a week, less than 2 pills a day.

Good luck.

Thanks for using MEDHELP forum.  

JF

[jcverive]

I am sorry to hear of your suffering, and I think you have every right to question the radiofrequency lesioning until you have had good results from a diagnostic nerve block.  Otherwise, the doctor will not know what part of the nerve to lesion.

Regarding your meds, I'm surprised to see triptans, unless there was a "working" diagnosis of migraine prior to the cervical facet syndrome diagnosis. Otherwise, calcium channel blockers and SSRI's (such as Elavil and most other antidepressants) are standard first-line medications for addressing nerve pain.

Other meds that have been used successfully for many patients include Lyrica (pregabalin - a very specific calcium channel blocker that is very good at reducing the hypersensitivity that usually accompanies neuralgia), Neurontin (gabapentin - effective at fairly high doses [over 3000 mg/day], whose mechanism of action is not well known), Keppra (levetiracetam - a powerful neurotransmitter antagonist), and Cymbalta (duloxetine - a selective reuptake inhibitor for both serotonin and norepinepherine). It is quite common to combine some or all of these to attack nerve pain from different modalities.  A final word on these (newer) meds: they have far fewer side effects than older meds like Elavil, Pamelor, and Tegretol (to name a few). The older meds are cheaper, but the dramatic reduction in side effects with the newer meds is usually worth the increased cost.

If all other less invasive procedures fail, you may still be a candidate for dorsal column stimulation, motor cortex stimulation, periaquaductal grey stimulation, or even deep brain stimulation. Please discuss these options with a neurologist and/or neurosurgeon. I truly wish you the best of luck.

[shaggy29]

Kim, does this describe you?

Broad feeling of tension in forehead and to a lesser degree the top of the head
Constant pressure feeling in head that is moderate to severe and NEVER goes away
Brain fog and feeling that you are somehow seperated from reality or living in a dream

Any other symptoms?   How do you diagnose CF syndrome?  is it easy to get a diagnosis?

[shaggy29]

Kim please email me we have much to discuss, I saw some of your other threads and remember our previous discussions  ***@****   and that goes for anyone else with these symptoms of head pressure and forehead tightness, email me.    I wish we could all pool our $$$ and head to the Mayo Clinic for evaluation...I bet if a group of us showed up we'd get alot of attention.

[shaggy29]

sorry, thats  HeadPressureHelp at aol dot com

[KimSb]

Hey Shag,

Yes, that's me to a T. I did follow "Joe West's" advice & called the Headache center. They referred me to an adept local Neuro who diagnosed me with CF based on my clinical symptoms. He said an MRI rarely shows it. He wants me to try the Botox, facet blocks & lesioning. I'm on the east coast so I'll hold da Mayo. :) Have you tried PT or Chiro?

I'll shoot you an email to discuss.

[KimSb]

JC, thx for your informative reply and suggestions. MY MD didn't think the new meds you mentioned would help me.

Any idea how and MD can determine if symptoms are coming from Occcipital Nerve compression or Cervical facet syndrome?

[jcverive]

Your MD has his own agenda. I'd bet dollars to donuts that he didn't explain why he thought the meds wouldn't work. That's what so many doctors said about BoTox for relieving nerve pain, because they don't care to research the actual mechanism of action of the drugs they don't understand well.  Instead, when such a doctor has already made up his mind about what procedure he wishes to pursue, there's very little most of us can do to change the doctor's mind (regardless of whether the patient wants to try something else).  Your choices are to 1) do what the doctor dictates, 2) continue to hound the doctor to try something else, or 3) "fire" the doctor and find one willing to allow you to be an informed member of your own treatment program.  Option #1 doesn't give you much option at all, and #2 is not likely to get you anywhere. Option #3 can be scary, because it is the greatest unknown, but it gives you the most control over your own fate.  You will have to decide which option suits you best, and I wish you much success no matter what you decide.  

To me, it seems reasonable to try a couple of different meds to avoid risky surgical procedures, but I am not a doctor. Best of luck to you!

By the way, the occipital nerve can be ruled out by performing diagnostic nerve blockade at the C2 dorsal ganglia (sensory nerve roots), though I would want the injections to be carried out by a disinterested party rather than by a doctor who has already concluded that the nerve in question is not involved.  It may be worth getting a referral to a local pain clinic in order to obtain a second surgical opinion.  Another option is to have a comprehensive neurologic examination by another MD or neurologist.  

[KimSb]

JC, again thx for your suggestions.

I am so sensitive to medications and was literally intoxicated by Keppra, Nerontin, Cymb, SSRIs, etc that my MD was loath to stay on that route. Even with extended trials, these meds reduced my already reduced ability to function. I'm seeing a pan clinic at an academic hospital and I have a 2nd opinion setup with a neurol who specializes in headaches. I've seen 6 Neurologists to date.

[RNRita]

Did you go to the Michigan Pain Center?  I think I read Joe West's post.  I contacted them and unfortunately, my insurance won't cover anything there.  I have the same symptoms and I also have fog and dizziness/wooziness that never seems to let up.  I am at wit's end as this is taking my life from me faster than a mugger!  Please keep posting and updating what you find.  I am finally gettin an MRI on Thursday.  I'm still scared, but I have the exact symptoms you guys have.

[KimSb]

No, I'm on the east coast & found an MD at a headache clinic at an academic hospital similar to Michigan. My MRIs & CTs were all neg.

[KimSb]

If you're out there, stop in & post, we need your success story as support & encouragement. :)

[shaggy29]

Well I'm still out here, but no success yet.  :(   I'm the guy with the osteoma/meningioma/whatever and deviated septum.   Those are my only 2 running theories.  

Kim, does your head pressure improve if someone stretches your neck out (physically supports the weight of your head)?

[shaggy29]

If you're not sure if it does or not  please try this and let me know.  If you don't have anyone to help with the experiment then stretch out your head yourself by holding onto your chin with one palm and the back of your head with the other and stretch your neck out by supporting the weight of your head,  or have someone stand behind you and slowly, gently stretch the head upwards and hold for 30 seconds....see what happens and let me know   please

[KimSb]

Shag, interesting experiment, albeit difficult to do alone. It does help reduce the pressure & tighness a little. What does it mean?

[shaggy29]

I wish I knew what it means.  I can only logically think of 3 things...  

1) Stretching of the neck leads to shifting of the brain and pulls it off my frontal tumor (I know this 1 wouldn't apply to you).
2) This is the most obvious answer but stretching the neck relieves some mysterious neck anomoly
3)  The CSF flow is improved through the forum magnum and/or the bloodflow is improved through the Circle of Willis (a group of arteries in the lower occipital area of the brain which flow from the vertebral arteries)

Kim, you say stretching your head upwards helps you.  Any chance you could get someone to help you with the experiment without them laughing at you?   To what degree does it help your symptoms?   Just a little? A lot?

The brain fog is really getting to me today, I don't even feel like I just typed all this out, if that makes sense.

[shaggy29]

Oh, and Kim...do you have significant neck pain or stiffness?   I did some Google'ing on cervical facet syndrome and saw that is one of the features of said condition..

[KimSb]

Yes, I have a sore & stiff neck as well. I've tried sleeping on my side & a Temper pillow.

Stretching the neck might relieve the pressure on the facets which a supposedly compressing the nerves & causing the pressure/tightness. Have you tried Cranial Sacral PT? Its supposed to increase the circulaton & CSF flow. I tried it with no success.

I sympathize w/you re:the fog. Man, it can get think somedays.  

A Neuro told me that an Osteoma would be seen by CT/MRI so do look into this w/your Neurol.

[shaggy29]

Check out my osteoma:

http://img124.imageshack.us/img124/5051/mri2go1.jpg

In case you missed it:

http://img257.imageshack.us/img257/7449/mri1ax1.jpg


So, as you can see, an osteoma is incredably easy to pick up on, for anyone with a basic knowledge of the way MRI's look.   Chances are you don't have a tumor of any sort, but it never hurts to look at your films yourself....the first hospital I was evaluated at was a smaller suburban clinic and their punk radiologist never made a report of it.   It wasn't until later, at a University hospital that this was shockingly brought to my attention.   Deep down, I assume this is the cause of my symptoms simply because it's the most obvious thing.   However, I still search in vain for other causes and cures due to the fact that I've received conflicting opinions from various doctors about whether this thing is causing my head pressure or not.

[KimSb]

Yikes, Raggy! :) Man, that's one heck of an osteoma! I would get many opinions on that one from both Neuro MDs & Neurosurgeons.  As U said, too obvious/

I've had 5 MRIs & 3 CTs, had them all read by Academic MDs & radiologists. 1 Neuro told me, it's te things we can't see or culture that are the hardest to diagnose, but posibly easier to treat... Go figure. Would be nice to get another opinion fro the CCF MD, as they're 1 of the best teaching hosp.  

[KimSb]

???

[shag469]

???, indeed, Kim.  They're answering new questions but not ours.  Mine is still waiting too.

How's the brain fog and head pressure going?  Still the same with me :(   These last couple of weeks have been especially bad