Occipital Neuralgia relieved with Use of Intrathecal Ziconotide
Alexander Yakovlev, MD; Angela Parmentier, APNP • Comprehensive Pain Management of the Fox Valley, SC
820 East Grant Street, Suite 335 • Appleton, Wisconsin, USA
INTRODUCTION
Occipital neuralgia is characterized by severe pain that begins in the upper neck and back of the head described as a sharp, shooting, zapping, electric or stabbing pain. Treatment typically involves occipital nerve blocks, peripheral nerve stimulation, steroids, rhizotomy or cryoneurolysis of the occipital nerves. Intrathecal infusion of Ziconotide has reported to be effective in bolus doses for managing pain associated with trigeminal neuralgia.
METHODS
A 33-year-old female patient suffering from occipital neuralgia for greater than 10 years presents with intractable occipital headaches. Initially greater and lesser occipital nerve blocks were preformed, after no sustained relief after peripheral nerve blocks; the patient underwent a peripheral occipital nerve stimulator trial. During the trial phase, patient reported 60% relief in her headaches, but was denied by insurance for implantation. Three intrathecal bolus doses of Ziconotide were trialed; 3 mcg, 4 mcg, and then 5 mcg of Ziconotide. Patient reported resolution of her pain after each injection and denied any cognitive side effects. Decision to proceed with intrathecal delivery system was made.
RESULTS
The first five months of the intrathecal infusion of Ziconotide, the patient reported 100% relief of headaches, but shortly after the patient started to report drowsiness and confusion with an intrathecal infusion rate of Ziconotide 7.651 mcg/day. Despite a 50% reduction in the infusion rate of the Ziconotide, the patient’s symptoms persisted. Adamant her occipital headache pain was relieved, several attempts to decrease the Ziconotide were made, until infusion was less than 1 mcg/day and the occipital pain returned. Saline was then placed in the intrathecal pain pump for a short duration until all cognitive symptoms resolved. Morphine at a rate of 0.500 mg/day is currently infusing producing pain relief adequate to the patient, but not as desirable as it was with the use of the intrathecal Ziconotide.
CONCLUSIONS
This is the first reported analgesic response to IT Ziconotide for chronic occipital neuropathic pain. IT Ziconotide was the only medication that resulted in 100% resolution of the patient’s pain. IT Ziconotide is well known for dose-dependent unfavorable side effects. Intrathecal bolus injections of Ziconotide reduced occipital neuralgia pain without side effects, however at a continuous infusion despite the dose, symptoms continued. IT Ziconotide should be considered for treatment of occipital neuralgia, however further investigation should be considered.
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