844 - Vertigo as a primary presentation of occipital neuralgia and resolution after lesser occipital nerve block

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

DN

Deklerk A. Ngankam, MD (he/him/his)

Resident Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States

Co-Author(s)

Kevin Franzese, DO

Assistant Professor of Physical Medicine and Rehabilitation
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, United States

Case Diagnosis: Occipital neuralgia

Case Description: A 57-year-old male fell and hit the back of his head without loss of consciousness. One month later, he experienced unilateral headaches, vertigo, imbalance, and nausea. After 14 months, he came to the concussion clinic. On examination, there was scalp hypersensitivity in the distribution of bilateral lesser occipital nerves, and double vision and vertigo with horizontal gaze and convergence. He was referred to vestibular and exertion-based therapy. After a month, his Dizziness Handicap Inventory (DHI) score fluctuated (mean score, 51), and the Activities-specific Balance Confidence (ABC) score increased from 52 to 87. However, he struggled with exertion-based activities. A 2 mL 1% lidocaine and 1 mL triamcinolone nerve block was done to the left lesser occipital nerve. Two days later, he reported complete symptom resolution. His DHI score (14) dropped by 68%, and his ABC score (95) rose by 8%. He was discharged from vestibular therapy because his symptoms resolved.

Discussions: Occipital neuralgia is a headache disorder caused by irritation or injury to the lesser or greater occipital nerves (derived from the dorsal and ventral rami of C2–4) and accompanied by dysesthesia or tenderness in the nerve distribution. Some patients present with vertigo or dizziness, nausea, and vomiting as the chief complaint due to an interplay between the upper cervical nerve roots and the vestibular nerves. Specifically, C2-4 nociceptive afferents traveling through the trigeminocervical nucleus (a site of convergence of cervical and trigeminal afferents) activate an aberrant pathway involving the vestibulocochlear nerve. Occipital nerve block dampens the pathway and leads to symptom relief, as observed in this case. At five months, he remains symptom-free.

Conclusions: A left lesser occipital nerve block effectively treated the vestibular symptoms of occipital neuralgia for up to five months. It can be considered as treatment to hasten the resolution of symptoms and discharge from therapy.