Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review.

The objective of this study was to assist clinicians in the diagnosis of the occipital neuralgia syndrome by describing its clinical characteristics. Bibliographies and clinical descriptions of occipital neuralgia syndrome were identified through a review of literature published between 1966 and 1993. A prospective case series was performed by the authors in a university emergency department during a 1-year period. Patients with unilateral aching pain of the head, coupled with pain in the distribution of the occipital nerve, Tinel's sign, and relief of pain after local anesthetic injection, were included. Patients rated pain relief on a 10-point scale. Twelve patients met the criteria for occipital neuralgia and were included in the study. All patients reported at least 80% decrease of pain after injection, and 42% had complete relief. Clinical features, other than headache, that were common in patients included tinnitus in 33%; scalp paresthesia, 33%; nausea, 42%; dizziness, 50%; and visual disturbances, 67%. Occipital neuralgia is a benign extracranial cause of headache, and it may be confused with other more serious headache syndromes. Recognition depends on an understanding of the symptoms along with a careful history and physical examination. Local anesthetic injections produce significant relief of the headaches and can aid in the diagnosis of the syndrome.

Basilar migraine.

Basilar migraine is a complicated headache which the International Headache Society describes as 'migraine with aura symptoms clearly originating from the brainstem or from both occipital lobes'. For years this headache was thought to originate from a transient disturbance in the vertebrobasilar circulation, but more recent studies suggest that a central neuronal disorder may be the source of migraine. Basilar migraines may have certain symptoms which are similar to other neurologic, vascular, psychiatric and metabolic diseases, yet there are specific criteria which can help differentiate it from other diagnoses. It is characterized by a throbbing occipital headache which may be preceded by an aura. The unusual symptoms of basilar migraine, which may precede and continue throughout the duration of the headache and even after it, include bilateral visual symptoms, altered mental status, vertigo, gait ataxia, bilateral paresthesia, bilateral paralysis and dysarthria. We describe a 29-year-old black female whose husband brought her to the emergency department complaining of confusion, headache, and left-sided weakness for 2 h prior to arrival.

Stiff-man syndrome: case report.

Stiff-man syndrome is a rare neurologic disorder characterized by progressive, fluctuating muscle rigidity with painful muscle contractions affecting predominantly the back and proximal extremities. In the ED, the diagnosis can be easily overlooked and misdiagnosed as acute or chronic low back pain and muscle spasm. This syndrome is often associated with diabetes, autoimmune diseases, and cancer. This report describes an illustrative case of a 39-year-old woman who presented to the ED with a two-year history of right leg spasms and low back pain that had become so severe in the preceding two days that she was unable to ambulate. Clues to the patient's proper diagnosis coincide with the diagnostic criteria for stiff-man syndrome: the presence of a slowly progressive stiffness of the axial muscles and proximal limb muscles, making ambulation difficult; hyperlordosis of the lumbar spine; episodic spasms precipitated by jarring or sudden movement; a normal intellectual, sensory, and motor examination when not in spasm; and a marked amelioration of symptoms with the IV administration of diazepam. High-dose oral diazepam is the maintenance drug of choice.