Headache Interventions in Practice: Finding the Cause of Severe Headaches

[Dr. Jacob Flemming]
I get a little bit antsy when I'm looking at fluoro pictures of the skull base and a needle going through someone's face. In radiology, we look at skull radiographs. To me, the diagnostic skull radiograph probably has one of the lowest yields, and yet, there's quite a bit that you can see on it, especially for procedural guidance. Could you talk about the movement from CT to fluoro and how did you mentally get over that hump?

[Dr. Dan Nguyen]
You're, absolutely, right about this. I am so appreciative of the early days of fluoroscopy, what they used to diagnose things. We're talking about decades ago and because they see so many things on there that we don't appreciate today, all the pathology. It took me looking at the fluoro picture and then looking side by side with the MRI and the CT. I look at it and go, "Well, if I take this approach, what is the worst thing that I can do? What things do I need to avoid?"

When I look at the approach to the foramen ovale, I go, "Wow, it's not a real lot of things here. It's not a carotid that's going to be there or anything." If I take this angle, there's really not a lot of things other than just sharpening my skill of advancing the needle meticulously without changing the direction and causing a lot of aggravation because this is a very sensitive area of the face.

Once I overcome the unknown of, "Oh, wow, this is putting someone's needle into the face," Once I understand the anatomy, it's really pretty safe if you just develop a right visual approach to it. That's what we say. I love to look at that. Once you have that, it's a straight shot into the foramen from the cheek area.

[Dr. Jacob Flemming]
It's really encouraging, much easier than expected, it sounds like.

[Dr. Dan Nguyen]
It is. Like I say, understanding the anatomy and looking at the things that we know from a cross-sectional image and going, "What is there that I have to avoid? That would be devastating if I hit it?" Once I overcame that, I didn't see anything and it was just a matter of getting used to the view from the fluoro perspective. It's so easy to do. It's just like C1, C2. You know what's going on there. I find it much easier doing fluoro than CT guided, C1, C2.

I can do a fraction of the time doing fluoro because it doesn't take a lot to set up. You can make some minor adjustments when you get the needle, which CT, sometimes when patients move a little bit, then you have to reset again. It's just a little more time consuming. There are times when you have to do CT, but there's some transitional phase where you just have to be yourself, look at the imaging and see what is there that I need to be not hitting? Once you see that, go, "Wow. Okay." Then you just overcome your fear.

[Dr. Jacob Flemming]
Sure.

[Dr. Dan Nguyen]
Like heights.

[Dr. Jacob Flemming]
Yes. It's a mental block. Once you understand, like you said, the procedure is done in the same manner as in CT in terms of the needle trajectory. We just are using image guidance in a different manner. I think it's something that's very important for trainees of my cohort in that we do a lot of procedures under CT, current resident and fellows in training. I think it has to do with probably availability and the comfort level. It's understandable. We do a lot more complex interventions, including drainages and things of that nature.

With that variable anatomy, it is good to have the three-dimensional aspect. When you're doing something like a trigeminal nerve block, a gasserian ganglion nerve block, you know, as you said, you're not going to be impinging on the carotid. There's not other critical structures nearby, and you have a little bit more of a reproducible approach. Knowing that CT and fluoro are both available and, of course, always using the approach that's the safest for the patient, but knowing that it's, definitely, feasible with both.

[Dr. Dan Nguyen]
There's one other modality that I want to give a little attention to. It's ultrasound. I think we have, in our radiology, we use ultrasound quite a lot, but maybe not in certain subspecialty in radiology. That is another modality that I integrate into our practice, especially in the superficial face, and then also peripheral nerves in the extremities too. That's another thing that I think has a large part in our guidance. Sometimes it's, actually, easier doing that way than any other ways that we're, thus far, been introduced to.

[Dr. Jacob Flemming]
Absolutely. A lot of love for ultrasound. It's such a dynamic modality. We tend to get quite a bit of exposure to this during our training. Adapting it to some of these places where probably in training we haven't used that much in the upper cervical spine or the face, it's, definitely, an important thing to do.

[Dr. Jacob Flemming]
You're probably seeing a wide variety of the manifestations of headache. With that, I imagine starting out from SIH, you had to, basically, bring more tools into your armamentarium. Can you just briefly talk about the different headache entities? Maybe just list the top five and what are the therapeutic approaches for those?

[Dr. Dan Nguyen]
Yes. Most of this, what I'm saying right now, I did not know back then either. It's one of those things that I think when you're doing something new, you start to dive into it and you start to read more. You start to look at the research and other societies, what they're doing, and it gets your interest. I go, "Wow, this whole area is a little more broader than I thought."

From there, typically today, I'm seeing a lot of the migrainous headache that has an occipital component to it. That could be just ranging from musculogenic nature, where we can do some simple trigger point to really an occipital painful with palpation, occipital neuralgia, where we can do a test injection and then we can do some ablative therapy. Then bring on neuromodulation, peripheral nerve modulation. I didn't even know what that was four years ago when I came to Oklahoma. "What is that?"

Those things I learned from my colleagues in the interventional pain world through my interaction nationally with them and brought that into our practice as well. That's the most I think of occipital neuralgia that I deal with. The other one is a cervicogenic headache, which you have to rule out. There's some people who have pain from their spine. I did not know there was a nice cervical, trigeminal connection in the brain, where your pain in the neck could manifest along the face, and vice versa.

There's that deep inherent connection and so you have to work through that too, was it coming from the spine where you're having pain in the face? Typical things you do for that is, okay, well, I look at the x-ray or CT or MRI, whatever that is. And see if there's any potential because of that and do some trial injection and then go from there to ablative therapy and, again, neuromodulation if needed.

Of late, I've been getting a lot of trigeminal neuralgia, mainly from trigeminal neuralgia centers around the Oklahoma State connection and people with MS are getting a lot of this. Certainly, deal with it from an imaging review and looking for vascular compression, but they have these really terrible, shocking pain that I feel so badly for these patients to live with this. We've been looking at ways to deal with that depending what region it comes from. Whether it's V1, V2, V3.

We know from anatomy there's areas of where these nerves come from. We, typically, do a trial injection of those areas like V1, supraorbital, suprachoclear, and then V2, infraorbital, and then frame of rotundum, we can access that through CT if you need to. Then V3, superficially mental nerve, and then could be as far back as foramen ovale where you can do that. I discover, I was very shy with fluoro beginning, but I discovered fluoroscopic guidance is so easy once you get to know where you can see it and much easier than CT to get there.