Amy Lin: A 46-Year-Old Female With Posttraumatic Occipital Headaches

Amy Lin

“He hit me right in the back of my head,” bemoaned Amy Lin. Amy had been my patient since moving to the city a couple of years ago. A successful nail salon owner, Amy seemed to have it all together. I had seen Amy for an upper respiratory tract infection about 8 months ago, but other than that, she was pretty healthy. Amy had called the office earlier in the week and asked if we could work her in because she had a pain in the back of her head that just refused to get better.

“Doctor, you know that husband of mine, Joe, is always getting hurt? Well, this time he decided to take it out on me.” Amy went on to say that about 3 weeks ago, she wanted to knock down a bird’s nest that was in the gutter over her patio door, so she asked Joe to get the ladder out for her. She was walking behind Joe as he carried the ladder, and when he suddenly turned, the ladder hit Amy squarely on the back of her head. “Doc, he really rang my bell! I saw stars, and it brought tears to my eyes. I gave him what-for and grabbed the ladder away from him before he killed me with it. I got the bird’s nest down, but for the past 3 weeks, the back of my head has been killing me. I’ve tried to tough it out. I tried all the usual stuff: tea tree oil, Motrin, the heating pad. Joe wanted me to go to the chiropractor, but I was afraid it might make my head worse. I think it’s about time to trade Joe in on a new and improved model.” I could tell that Amy was getting really wound up about Joe, so I reassured her that she had done everything right, except perhaps letting Joe carry the ladder. I asked her if she had ever had headaches before and she shook her head no. “So, no loss of consciousness?” and again she shook her head no. I suggested that we look her over to figure out what was wrong and what we could do to make it better.

I asked Amy to point with one finger where it hurt the most. Amy pointed to her left occipital region, and then pointed up toward the vertex of her scalp. “Is there any numbness?” I asked. Amy replied that the left side of her head felt like it was asleep. “You know, Doctor, that weird pins-and-needles feeling that you get when your foot goes to sleep.”

“Are you having any visual problems, or is there anything else that I need to know about?” I asked.

“Nothing but my husband, Joe. He means well, but he is always an accident waiting to happen.”

“Let’s put you in a gown and take a look,” I said.

On physical examination, Amy was afebrile and her respirations were 16. Her pulse was 74 and regular, her blood pressure a nice 110/68. Palpation of her cranium revealed no mass or other abnormality. Her head, eyes, ears, nose, throat (HEENT) exam, including fundoscopic examination, was normal, as was her cardiopulmonary examination. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Palpation over the left greater and lesser occipital nerves elicited a shocklike pain that radiated from the nuchal ridge to the top of her head on the left. Her neurologic examination was otherwise within normal limits. There were no pathologic reflexes.

Given the history of trauma, I ordered a magnetic resonance imaging (MRI) of the brain to rule out any occult pathology.

Key Clinical Points—What’s Important and What’s Not