Case Report: Female with headaches, facial pain, and paresthesia Mark H. Street, D.C. jet@sonic.net revised 1/23/96 A 39 year old female junior accountant, 126 lb., 63", right handed, entered our office with headaches. The patient complained of approximately 5 headaches per week located in the occipital area, and bi-temporal. The headaches are worse on the left, occasionally a sharp pain in the left temporal area, they are made worse by stress. The patient thinks the headaches are caused by tension and she feels the problem is getting worse. Her vision and hearing are very sensitive during episodes of headache. The patient takes 2-4 aspirin per day and wonders if this really helps. The pain is described as vice like, gripping headaches, muscle tension, she states she feels off balance, the timing is constant. The left jaw and associated facial area and musculature was painful to touch, it was worse at night and with increase in stress, nothing helps symptoms improve. The patient has to sleep on her right side because it hurts her jaw to sleep on the left side. The patient complains of atypical facial numbness and pain, neck pain, and dizziness. The symptoms are constant most of the time, sometimes they come and go. The patient is a jaw clincher. The patient states she has been taking Elavil medication and it helped the symptoms for a while, she states she is now coming off the medication and the headaches are coming back. The patient states she had an episode about 2 months ago, after a time of overload and stress when her vision blurred and she felt like she had a seizure, possible amnesia, she states she was wiped out physically after the episode. The patient describes dull low back pain which is worse when sitting, exercising, and at menses. Past history a car crash in 1956 in which she suffered a head injury, of what type she does not recall. Car crash 1981 or 1982, no injury known, she does recall that her vehicle was struck from the right side, she remembers some left shoulder discomfort at the time but did not think the injury was significant- did not seek treatment, 1981 breast implants, 1987 tubal ligation. Current medications included; Progesterone, Anaprox, Elavil, Aspirin Immediate past medical history Patient has an examination from a Neurologist on October 8, 1991, his impression is atypical facial numbness and pain, that may be related to TMJ joint dysfunction, but he thinks search for other etiologies is warranted. The patient he states is, anxious to get to the bottom of this difficulty if at all possible. Her doctor proceeds to do diagnostic testing as follows. MRI scan of the head and sinuses, to exclude inflammatory processes or space occupying lesions. Blood drawn for screening panel, thyroid function, VDRL and arthritis panel including sed rate, an ANA and rheumatoid factor. No medication at this time. Results of tests blood work Normal. MRI scan of brain and sinuses No intracranial abnormalities identified. Findings consistent with left maxillary sinusitis. The patient elected to live with the problem over the next year, but in further discussion with her dentist, a decision was taken to have her case reviewed by a prominent southern California pain management center associated with the University’s school of dentistry. The patient was examined on August 18, 1992 with complaints of: 1. Numbness in the left cheek spreading intermittently as a tingling sensation into the left upper lip and in previous history into the left lateral border of the nose. 2. Pain and pressure in the angle of the left mandible which increases with facial expressions but is not affected by chewing. 3. Bite discomfort 4. A history of twitching around the left eye which was significant one month ago but now is reducing. The patient states that she could precipitate this by just touching the left cheek or face. 5. Bilateral temple and occipital headache without nausea or aura but with some photophobia. The headache occurs approximately four times a week and the patient self treats. 6. Bilateral cervical pain with cracking on movement of the neck. Assessment: 1. Dysesthesia of the trigeminal nerve involving the third and second sensory divisions and with a historic motor component affecting the outer corner of the left eye. 2. A chronic daily headache of low level 3. Myofascial pain of the jaws and neck 4. A minor sleep disturbance 5. Tendency for joint hypermobility 6. Local dental sensitivity upper left quadrant where two crowns are scheduled for replacing. 7. Occasional breakthrough migraine headache 8. History of unstable blood pressure 9. Some postural hypotension 10. Some workplace and social stresses Recommendations: 1. Follow-up with neurologist involving trigeminal nerve symptoms 2. Follow-up MRI 3. Other DDX considerations, compression of 7th cranial nerve passing through parotid gland, middle ear pathology, demyelination of the sensory part of the trigeminal nerve, possible viral infection in the distant past, pt has history of non specified viral infection between age 12 and 14. 4. diagnostic trial with tricyclic anti-depressant, Elavil 5. diagnostic trial with peripheral stabilizing medication namely Tegretol or Baclofen. 6. physical medicine care for rehabilitation of the myofascial component. The patient received a letter on Sept.19, 1992 stating a delay in treatment program was due to bad communications between her doctors. She was referred to a local physical therapist for Trigger Point and myofascial work to her head, jaw, and neck. November 16, 1992 The patient had another neurological evaluation from another neurologist. Impression: 1. This patient describes an episode which occurred last Friday, November 13. The patient complained of lightheadedness followed by a feeling of intoxication and semi-consciousness that lasted several hours. Her hands became shaky and she appeared poorly coordinated. She was put on the couch and then appeared semi-conscious. She started having hiccups. The patient was taken to a local emergency room, a complete blood panel and EKG performed shortly after that were normal. It seems unlikely to have been a seizure phenomenon, although this remains a consideration. She has had no prior or subsequent episodes similar to this. 2. Chronic vascular and tension headaches. 3. History of left face pain of uncertain etiology which has now resolved. Recommendations: 1. An electroencephalogram will be performed to screen for evidence of seizure activity. 2. A return visit has been scheduled. 3. An empirical trial of tricyclic compound will be considered at that point. Nov. 20, 1992 Follow up, patient continues to describe recurrent episodes of light- headedness and daily headaches. EEG entirely normal. Repeat neurologic examination also normal. Started on Elavil 25mg for treatment of muscle contraction headaches. Return in 2 weeks. Dec. 4, 1992 Follow up, headaches have steadily subsided. No headaches in 2 weeks, continue with medication, if headaches return contact for re-evaluation. Jan 11, 1993 Examination in our office, patient asks to evaluate her problem looking for a recommendation for the best type of care. Range of motion of the cervical spine was normal, some pain was produced in right rotation on the left side of the cervical spine, lateral flexion with compression caused pain bilaterally, Soto Hall test caused pain in the cervical and thoracic spine, reflexes and brachial plexus dermatomes were normal, spinal tenderness was noted over a VERY prominent left atlas (C1) transverse, and the over the left ramus and angle of the jaw. Muscle spasms noted in the sub-occipital region bilaterally, muscle spasms were also in the left rhomboids, and left lumbar paraspinal muscles. Trigger Points were noted in the left massiter muscle, temporalis muscle and in the immediate area of left atlas transverse. Examination of the TMJ and surrounding soft tissues revealed palpable tenderness over the angle of the left jaw extending superiorly to the massiter muscle and posterior to the left transverse process of C1. Bimanual palpation of the TMJ bilaterally did not reveal any apparent crepitus, cracking, clicking, or grossly apparent abnormal joint tracking. Most notable was that active TMJ joint motion did not elicit an increase in the patients symptomatology or cause pain in the TMJ joints bilaterally. Anterior thrust of the jaw caused pain in the left TMJ. This doctors evaluation of the TMJ was merely to detect any gross pathology which might be readily apparent, this doctor does not profess to be a specialist in pathology of the TMJ. Radiographic studies were performed on the cervical spine, a 4 view cervical series, AP, Lateral, Flexion, and Extension. The ADI measured 2mm.. The digastic line was within normal limits. Spinolaminar tract and George’s line were within normal limits. There was no apparent fracture or soft tissue pathology. This doctors subjective visual opinion of a mild to moderate cervical hypolordosis, mild uncinate arthrosis ate C5-C6 motor unit. A trial of chiropractic adjustments was performed on the cervical and thoracic spine and supporting spinal structures. Cervical adjustments were this doctors version of a modified rotary break as taught at Palmer College of Chiropractic-West. C5 was adjusted from the left, National Listing (PRI-L), C2 was adjusted from the right, National Listing (PLI-L), and C1 was adjusted left lateral. Thoracics were adjusted anterior, due to patients breast implants. The patient was treated intensively for 1 month, re-evaluations were performed twice during the first 5 weeks. Before each visit the patient filled in an analog pain scale for each symptom; headache, neck pain, and facial and jaw discomfort. The patient was also asked to rate the symptoms better, same, worse. After 5 weeks the patient states a percentage of improvement in headaches as 90%, neck pain 100%, facial paresthesia 70%. The patient is satisfied with her care, she has been able to follow the doctors recommendations. Other treatments performed were cervical rehabilitation on a 4 way neck machine using standardized Zinovieff and Delorme Watkin rehabilitation protocols, interferential current bipolar on the massiter and sub-occipital muscles several times during the first 5 weeks. This patient was seen by this doctor 19 times in this period of time. Unfortunately this doctor moved and has since not followed up on this patient. The patient was left in the care of a chiropractor who is a certified craniopath with experience with TMJ. Mark H. Street, D.C. mstreet@nermal.santarosa.edu