Vertebral Dissection

Headache is one of the main symptoms of Vertebral Dissection. In one of the biggest studies (over 161 cases of vertebral and carotid dissections), 69% of vertebral cases had headache. Almost all reported pain - back of the head (83%), non-pulsatile (56%), pulsatile (44%). Pain located in the neck was found in 46%. Most headaches resolved within 72 hours.

Sometimes the diagnosis of vertebral artery dissection is not so straight forward. There are several reports of cluster headache actually being associated with dissection of the vertebral artery on the same side as the cluster headache. These patients reported intermittent pain around the eye with watering of the eye, but at the very onset neck pain was sometimes found (always pays to go back to the very start when taking headache histories!)

High resolution CT angiography can reveal arterial dissection, as can MRI Angiography. It is not usually necessary to have formal catheter cerebral angiography unless an intervention such as repair of a pseudo-aneurysm is planned.

The prognosis for the patient will depend on whether there has been a stroke. About 12% of vertebral arterial dissection will have headche and headache alone. A stroke or TIA is a common finding in vertebral dissection, and 3% will have imaging findings of subarachnoid haemorrhage. Usually the dissection, at imaging, is found at the C1/C2 vertebral level (>70% cases). A mortality of 2% has been reported.

Other conditions that could cause a pain in the back of head:

1. Vertebral Dissection
2. Occipital Neuralgia
3. C2 root pain e.g. atlanto-axial dislocation
4. Third occipital nerve pain (post-traumatic C2-3 zygo-apophyseal joint pain)
5. Neck-tongue syndrome - atlanto-axial subluxation, causing neck pain and tongue numbness (some sensory tongue fibres pass through C2 spinal nerve, not trigeminal nerve)

The course of the vertebral artery in the neck. Courtesy of Bartleby.com Creative Commons License.

References

Marcel Arnold et al. Vertebral Artery Dissection. Presenting Findings and Predictors of OutcomeStroke. 2006;37:2499 (Full Free text)

Lord S et al. Third occipital headache. A prevalence study. Journal Neurology Neurosurgery and Psychiatry 1994;57:1187-90. (Free Full text)

Lance and Anthony. Neck tongue syndrome following rapid turning of the head. Journal Neurology Neurosurgery and Psychiatry 1980;43:97-101. (Free Fulll text)

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