Resident Kessler Institute for Rehabilitation Jersey City, New Jersey, United States
Case Diagnosis: Vertebral Artery Dissection
Case Description: A 43-year-old female with a history of migraines presented with two weeks of an occipital headache. Typically, her migraines were bitemporal and associated with photophobia and nausea lasting 48-72 hours. This headache was occipital, rated 10/10 and constant without any associated symptoms. Her physical exam was unremarkable without any neurologic deficits. Non-contrast CT head scan showed no acute abnormalities. She initially received intravenous fluids, ketorolac, acetaminophen, and metoclopramide after which she continued to endorse 10/10 pain. Patient was offered and consented for a greater occipital nerve block. Using anatomic landmarks, 4cc of 0.25% bupivacaine was injected after negative aspiration. Within 10 minutes, her pain score improved to 1/10.
After 48 hours of relative pain relief, the patient returned with the same headache rated 9/10. She received a CT angiography of the head and neck which revealed an extracranial vertebral artery dissection. She was seen by neurology and started on aspirin.
Discussions: Vertebral artery dissections are a rare entity. They are most common among young- and middle-aged patients and typically associated with some form of neck trauma or cervical manipulation. In this case, there was no prior insult or past medical history that could be attributed to the dissection. Atypical headaches can be difficult to evaluate. While this patient had resolution of symptoms after a greater occipital nerve block, the return of the same symptoms raised concern of an alternative underlying etiology requiring further investigation. In this case, the patient had a vertebral artery dissection without any neck pain or neurologic deficits.
Conclusions: Vertebral artery dissections can vary greatly in their presentation. While greater occipital nerve blocks are a great tool in treating occipital migraines, the recurrence of symptoms after anesthetic effect wanes should warrant further investigation.
