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BackTable / MSK / Article
Headache Interventions in Practice: Finding the Cause of Severe Headaches
Melissa Malena • Updated Jul 4, 2024 • 31 hits
Evaluating and diagnosing severe headaches can be a formidable task for interventional radiologists at the start of their interventional practice. Correlating imaging with clinical examination and patient-reported pain patterns often proves challenging. Dr. Dan Nguyen, former president of the American Society of Spinal Radiology, shares practical tips and tricks for identifying the source of severe headaches. Learn more about the most common headache presentations and how to build confidence with your diagnostic approach.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• After the initial learning curve, fluoroscopy is often easier and quicker than CT-guided C1 and C2 headache imaging.
• For the optimal cranial imaging results using fluoroscopy, approach the foramen ovale and evaluate the angle of continuance before changing the needle’s trajectory.
• When attempting to correlate imaging with clinical evaluation, evaluate the nerves that innervate the location of pain as a base point of investigation.
• The most common headache manifestations in headache interventional practice are migrainous headache, occipital neuralgia, cervicogenic headache, and trigeminal neuralgia.
Table of Contents
(1) Imaging for Headache Interventions: CT vs Fluoroscopy vs Ultrasound
(2) Correlating Clinical Findings with Imaging in Interventional Headache Treatment
(3) Interventional Options for Common Headache Presentations
Imaging for Headache Interventions: CT vs Fluoroscopy vs Ultrasound
Practitioners may be intimidated by fluoroscopy, as it involves delicate handling of needles while more traditional imaging involves simply placing the patient in a machine. However, fluoroscopy can provide significant benefits in visualization compared to CT scans.
When implementing fluoroscopy, Dr. Nguyen recommends approaching the foramen ovale and evaluating the angle before changing the needle’s trajectory as the target is a sensitive facial area that is prone to aggravation. Once radiologists have overcome the discomfort of managing a needle and have grown confident in their visualization of the anatomy, fluoroscopy can be a much easier technique than CT-guided C1 and C2 imaging. Dr.
Nguyen also suggests implementing ultrasound as an imaging modality due to its dynamic and flexible nature. Ultrasound proves particularly helpful for imaging the superficial face and peripheral nerves of the extremities.
[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.
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Correlating Clinical Findings with Imaging in Interventional Headache Treatment
Patients often present to interventional headache specialists with imaging from the emergency room, where glaring abnormalities such as intracranial hemorrhages have been ruled out. Such imaging proves difficult to correlate with clinical findings and patient descriptors of pain. When analyzing such imaging, Dr. Nguyen recommends focusing on the neuroanatomical supply of the face and looking for what anatomically correlates with the patient’s complaints. In the areas where the patient is experiencing pain, you can look for vascular compression or vessel damage. If this proves unsuccessful, Dr. Nguyen suggests troubleshooting by assessing the nerves that innervate the area of pain and using those nerves as a basis for investigation.
[Dr. Jacob Flemming]
On that note, I'd, actually, like to transition a little bit to talking about some of the headache interventions. One of the things I've been thinking about with this, and I'll say, I haven't performed any headache interventions at this point in my career other than for CSF hypotension. I know a lot of these interventions involve really very eloquent and small real estate, particularly at the skull base.
As radiologists, whether we're trained in neuroradiology or not, throughout our training, we read thousands of head CTs. It's probably one of the single most common studies that we read, and often for the indication of headache.Yet, most of the time, our impression is sort of, "No acute intracranial abnormality." I'm wondering if you can talk about the clinical evaluation of headache, and then how the imaging aspect comes into that? Are there often any imaging correlates to these headache syndromes, and how do you spin that all together?
[Dr. Dan Nguyen]
I think the imaging that we see day in and day out, a lot of it coming from the ER. They look for big stuff. The big intracranial hemorrhage, or a mass, or unexpected mets, or something. Yes, we see that, but even normal people have headaches. You look at that, most of the time, it's normal. Then it's really hard to correlate that clinically, unless you have a patient sitting in front of you and describe to me, "Doc, I have this pain right over my eyebrow," or, "I have this pain right in my jaw lines."
Some specific region now gets you thinking of the neuroanatomy supply of the face. Then you go back there and look at that and sometimes you find something, but most of the time it's negative. Certain things like trigeminal neuralgia, they have this pain, an electrical pain over their face, but you don't see anything on the imaging. Every once in a while a vessel next to it, which probably was not, to be fair, difficult to catch in the front end from the original interpreter. Yes, you can suggest that maybe there's a vascular compression syndrome that may be causing that.
On rare occasions, you find that most of the time you don't, but it's good. Then now you go back to your understanding of the neuroanatomy of the face. Then, you troubleshoot, "Okay, if it's in the front of the ear, maybe it's an auriculotemporal nerve that may be bothersome." Some other areas may be supraorbital, infraorbital, mental. There's different nervous supplies of the face and our understanding of the anatomy helps us to hone down now and say, "Okay, we'll try the most superficial approach and then we'll dive into the deep part of the skull and facial region as a secondary backup option.
Interventional Options for Common Headache Presentations
In his practice, Dr. Nguyen sees many migrainous headaches featuring occipital components, which are often caused by musculoskeletal issues or occipital neuralgia. Occipital neuralgia frequently presents with tenderness to palpation of the occipital region in a clinical exam and can be confirmed via test injection. Occipital neuralgia can be treated with ablative therapy, neuromodulation, and peripheral nerve modulation.
It is important to keep in mind that cervicogenic headache, or pain originating from the spine that is experienced in the face, is also a possibility. Suspected cervicogenic headaches can be confirmed using CT or MRI imaging featuring a trial injection, and treated with ablation therapy and neuromodulation.
Recently, Dr. Nguyen has seen many trigeminal neuralgia cases, as it is a comorbidity with multiple sclerosis. In these cases, he recommends evaluating for vascular compression and using CT or fluoroscopy trial injections in the V1, V2, and V3 areas, depending on the patient’s pain locale.
[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.
Podcast Contributors
Dr. Dan Nguyen
Dr. Dan Nguyen is an interventional radiologist specializing in interventional pain management with Neuroradiology & Pain Solutions of Oklahoma.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 6). Ep. 30 – Image-Guided Headache Interventions [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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