809 - Too Much Teleworking? Atypical Occipital Headache Secondary to Enthesopathy at the Occipital Protuberance: A Case Report

Case Diagnosis: Occipital Headache Secondary to Enthesopathy at the Occipital Protuberance

Case Description: 51-year-old male with history of migraine presented to clinic for second opinion evaluation of a new occipital headache. Since childhood, his typical migraine is bifrontal headache with photophobia and nausea. About 8-months ago, he developed a new headache type that would awaken him overnight. He describes sharp pain localized to his occipital region. Several months before symptom onset, he notes increasing screen time usage and teleworking. No known head or neck injuries. Previous treatment with Gabapentin and Sumatriptan for presumed occipital neuralgia and migraine was unsuccessful. His exam was only notable for pinpoint tenderness at the occipital protuberance which reproduced his symptoms. CT Head was obtained, which revealed hypertrophy of the external occipital protuberance (at the attachment site of the ligamentum nuchae and trapezius muscle), suggestive of enthesopathy. For suspected enthesopathy-related pain, a trial of indomethacin, methocarbamol, with home trapezius relaxation program resulted in complete headache resolution.

Discussions: Enthesopathy typically occurs in the setting of overuse injury or an inflammatory process, largely affecting peripheral joints. As part of this condition, patients can develop enthesophytes, which may be symptomatic. We hypothesize that prolonged cranio-cervical flexion and altered body posture with virtual work, may have contributed to overuse injury and the development of an enthesophyte in this patient. Several recent radiology studies suggest increasing prevalence of occipital protuberance enthesopathy amongst younger patients due to poor ergonomics and biomechanical stress, which can be seen with remote work/learning and texting.

Conclusions: This case highlights an atypical cause of occipital headache secondary to enthesopathy. Early recognition with dedicated head imaging is key in initiating proper treatment with routine conservative therapies such as NSAIDs and a dedicated home exercise program. Additionally, this case further supports the necessity of optimal remote workplace ergonomics to prevent the development of this condition.