Chiari, medication overuse headache, migraine?

Health Professional

Full Question:

11 yrs ago I had a very acute occipital head spasm. The intensity gradually reduced but it didn't go away. It was and remains fairly localized except to extend into my ears. Diagnosed with migraine; started on amitriptyline. didn't help. I also had a pain in the base of my throat between my collar bones that occurred whenever I used my arms. Most recently, I lost my balance severely while working with light off and my arms hurt to hold up for any amount of time. The headache and throat pain is worse and waking me ever earlier. An ENT referral found a Chiari Malformation. ENT advised Neuro referral. Saw neuro on 2nd Dec he couldn't view MRI but said report about Chiari was within normal limits so not to worry about it. His conclusion is I have Medication overuse headache (paracetamol) and Basilar migraine. I had 4 Nerve Occipital block injections I am not to take any analgesics and have started topiramate. Actually speaking is hard and hurts my head/throat. I'm just not convinced as I didn't regularly take paracetamol the pain wakes me I need to get vertical I intend to take tablets but when I'm up I'm feeling sick and dizzy but head a bit better so often don't. I've agreed to do this but am suffering with the throat shoulder arm and back pain as well as the headache. Id appreciate an opinion. Can the Chiari be that easily dismissed? I am getting very depressed have spent a lot of money at physio chiro trying to be proactive. Debbie.

Full Answer:

Dear Debbie;

Chiari malformations, especially the ones referred to as Type 1 malformations, often create difficult treatment dilemmas. These are often seen on MRI imaging of the brain or cervical spine, even in people without any symptoms related to them. The malformation is seen as a small amount of brainstem and cerebellar tonsil (the bottom, most midline part of the cerebellum) extending into and through the hole at the base of the skull where the spinal cord comes through (foramen magnum). Sometimes they can be associated with a small fluid collection in the upper spinal cord as well (syrinx).

The symptoms you are describing of headache and dizziness can be associated with a Chiari malformation, but the throat, shoulder, arm, and back pain would not. First, I think it is very important for you to ensure that your neurologist actually views the MRI films. It is really impossible to determine the extent of a Chiari based solely on the radiology report. Second, given your other symptoms, it may be necessary to image your cervical spine as well to look for a syrinx, as this could more easily relate to some of your other symptoms. Occipital nerve blocks can be helpful to break the cycle of headaches, and use of paracetamol (acetaminophen for those of us in the US) or other pain relievers can lead to medication overuse headache (MOH), especially if used more than 2-3 days per week. To understand better, read Medication Overuse Headache: When the Remedy Backfires.

It is important to remember that the vast majority of the Chiari malformations seen on MRI scans are not clinically relevant. Your symptoms may very well have nothing to do with it. But it is very important to make sure of this, so please go back to your neurologist with a copy of your actual films or see another neurologist who will re-evaluate your scans.

Chiropractors seem to be helpful for some people with migraines or other headache disorders, but the evidence for this is limited. Until your Chiari malformation has been more thoroughly evaluated, I would avoid allowing anyone to do significant manipulation of your head and neck. Physical therapy should be fine if it is helpful to you, but high velocity neck adjustment should be avoided.

Thanks for your question,
David Watson, MD


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Dr. David Watson is a UCNS certified migraine and headache specialists and director of the Headache Center at West Virginia University. He and Lead Health Guide Teri Robert, team up to answer your questions about headaches and Migraines. You can read more about _ Dr. Watson_ or more about _** Teri Robert** _.

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