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Headache in a Patient With Crowned Dens: Report of a New Case
Author(s) -
Viana Michele,
Sainaghi Pier P.,
Stecco Alessandro,
Mortara Franco,
Sprenger Till,
Goadsby Peter J.
Publication year - 2014
Publication title -
headache: the journal of head and face pain
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.14
H-Index - 119
eISSN - 1526-4610
pISSN - 0017-8748
DOI - 10.1111/head.12383
Subject(s) - medicine
Background Crowned dens syndrome ( CDS ) is a clinical‐radiological entity characterized by acute attacks of neck pain with fever, rigidity, general signs of inflammation, and calcification of the periodontoid articular structures. Methods Case report with 42 months follow‐up. Case description An 81‐year‐old man, who had never suffered from headache before J uly 2010, developed strictly left‐sided headaches. The pain was restricted to the left side of the scalp and felt more intense in the frontal area. The intensity was moderate to high with a throbbing quality. The pain had an orthostatic component and was worsened by neck hyperextension and V alsalva maneuvers. Neurological and general examinations were normal, except for a reduced range of motion of the neck. He was prescribed indomethacin orally 25 mg t.i.d. and had a partial response. After a week, he was given a dosage of 50 mg t.i.d. with complete remission of the pain. Brain magnetic resonance imaging was normal, while an magnetic resonance imaging of the cervical spine showed a non‐homogeneous mass behind the odontoid process of C 2, narrowing the subarachnoid space in C 1, stretching the posterior longitudinal ligament, and touching the left vertebral artery. A computed tomography scan showed calcification of the soft tissue around the odontoid process and a thickening of the left C 2 root. After 4 months, the indomethacin dosage was reduced step‐by‐step. Indomethacin was discontinued in M arch 2012. Since then, the headache has not recurred. Discussion We here present the case of a patient with headache and radiological findings of crowned dens. However, the clinical presentation differed from previous CDS cases in the literature in that the pain was unilateral with frontal localization and throbbing quality, as well as an orthostatic component and lack of either fever or inflammatory signs. The differential diagnosis also includes a remitting form of hemicrania continua, presenting with an atypical presentation, with neuroimaging incidental finding of CDS . Conclusion This case widens the spectrum of the clinical presentation of crowned dens, a condition that should be kept in mind in cases of unilateral headache in older patients.