Case Diagnosis: Persistent headache after cerebellar stroke with hemorrhagic transformation
Case Description: 86yo M with PMHx hypertension, hyperlipidemia, BPH, atrial fibrillation (not on anticoagulant) presented to the ED with new onset headache associated with diaphoresis & tinnitus. Found to have left cerebellar infarct on MRI with noted deficits in balance and gait on exam. Once stabilized, patient transferred to acute rehab. Headache/dizziness persistent during admission. Dizziness unresponsive to trial of meclizine/reglan which was discontinued due to concern over urinary retention/confusion; headache unresponsive to tylenol. Repeat imaging obtained two weeks post-admission revealed hemorrhagic transformation. Due to headache persistence, pain management consulted who recommended consideration of greater occipital nerve block. Hemorrhagic transformation stable on multiple repeat CT scans and patient brought to outpatient clinic for recommended injection with combination of lidocaine, bupivicane & depomedrol. Patient had significant improvement in headache symptoms with only mild tenderness at injection sites in the days following. He was discharged from rehab to home the week following injection.
Discussions: Occipital nerve blocks are considered a treatment option in various etiologies of headache including chronic cluster headaches, migraines, occipital neuralgia & post-dural puncture. However, there is limited data in regards to occipital nerve blocks in patients with persistent headache after stroke. The incidence of headache after stroke varies among studies and is recorded to occur in somewhere between 9% & 38% of patients. It is more common in those with intracranial hemorrhage due to irritation of surrounding structures. Other means of treatment (ie. NSAIDs) are frequently avoided in these patients particularly during the acute period after hemorrhage due to increased risk of bleed. Thus other methods should be considered.
Greater occipital nerve block may be a treatment option in patients with persistent headache after hemorrhagic transformation particularly in those in whom other options are not viable or in whom conservative management has failed.