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Nasal pain on one side, pain above eye around occipital bone, neck pain around the cervical vertebrae. MRI, CT normal. Underlying cause?

Patient is a male, asian, married, bank officer, 49, presenting with generally three aches. First type, a one sided nose pain simultaneosly with pain at a specific region on the head (roughly around the middle of the parietal lobe ), often simultaneously but may occur independantly. Patient is unable to distinguish specifically whether the origin is the left or right lobe. Second type, pain above the eye roughly around the occipital bone on the right side. Third type pain at the neck, posterior, roughly about the region of the cervical vertebrae , and may sometimes radiate to the superior part of the trapezius muscles proximal to the cervial vertabrae. All the types may occur individually or simultaneously. These pains have existed throughout his adult life. Multiple MRI scans revealed no lesions or abnormalities on the brain specific to the symptoms. CT scan of the nose suggests the same. On incidental finding, patient has a pineal cyst. On comparison with previous scans within an acceptable time range, it is believed to be benign. On other issues, patient has had his gall bladder resected due to cholelithiasis approximately 10 years ago. Patient has moderately high cholesterol , with long term medication of Rosuvastatin. Patient has no history of hypertension or diabetes. Patient complains of an unexplainable phenomenon that occurs during driving a vehicle. Closely described as a pre-syncope, and an altered sense of motion, but does not faint or blackout. Patient was put on Betaserc(betahistine) to resolve the problem, but showed little to no improvement. Patient also complains of tinnitus and a feeling of high pressure in the ear on other occasions but rarely. 9 months ago, patient had an automobile accident (patient was a pedestrian), with trauma to the head that resulted in a superficial injury and an intracranial haematoma that has been resolved. During the recovery period patient has had blur visions medial field view, that also has been resolved now. Also from the accident, patient had a comminuted fracture in the humerus proximal to the shoulder joint, and has a surgical implantation. There were fractures to the T3 and T4 and also a complete fracture to the clavicle. Patient has no recollection of the incident. Patient has had a history of severe migraine headaches that began from his teenage years, that halted approaching his forties. In his early years, during severe episodes of migraines, patient used Ponstan (mefenamic acid) to relieve the pain. A few years later patient developed hypersensitivity towards the medication. The symptoms that the patient is presenting with (the three aches) is not a migraine attack, and describes the pain as being an annoyance. Patient is on chronic usage of paracetamol, cerebrex, arcoxia, and sometimes the combination of those to relieve the pain. A few years ago, patient often used 5mg of xanax (alprazolam) quite regularly to relieve the pain and get some good sleep. Often the patient has inadequate sleep. Patient often believes that its the food ingested or indigestion that is causing his symptoms due to the fact that the pain sometimes appear after having certain kinds of food, especially shrimps, and taste enhancers. The patient reduces his food intake due to the believe that indigestion is causing his symptoms. Patient is also often subjected to stress due to work. The pain often inter switches among the three types. No liver scans has been done to assess the toxicity of the medication on the liver, but recent blood test revealed no elevated liver enzymes. Patient is not an alcoholic, drinks occasionally but on small amounts, not a binge drinker. Patient sometimes has troubles with defecation, often with polarized outcomes of either constipation or mild diarrhea. There are no elevation of creatine kinase that may indicate any cardiac or renal abnormalities. An MRA of the cephalic region has been done and reveal no abnormalities. The pain concern is the three types of pain mentioned first. The other info is just to feed in the patient history. What could be the underlying cause?
Asked On : Tue, 29 Jan 2013
Answers:  1 Views:  89
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Emergency Medicine Specialist 's  Response
Thanks for writing your query.

After reading your post, it seems that the patient is having attacks of migraine resulting in the pain described by you.

Single sided headache associated with lack of sleep and stress with associated symptoms of tinnitus and aggravating with some kind of foods suggest towards migraine only. In persons with head injury, the migraine headaches may be more severe.

You can start treatment for migraine like Flunarizine 10 mg at night and should take paracetamol along with domperidone when the pain appears to start.

I hope this may help your patient.
Answered: Tue, 29 Jan 2013
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