Transcranial Low Level Weberneedle Laser in the Management of Intractable Headache: Case Report
Background: Chronic headache is persisting pain located above the orbitomeatal line. Refractory headache is a devastating form. Tension type is the most common form, while 13.8% suffers from cervicogenic headache. Interventional management for these types of headaches was described. We are reporting 2 cases with refractory headache and their management by applying low level transcranial laser. 
Case Report: Spine Care Center in Cairo, Egypt presents 2 cases of intractable headache from January to November 2016. Follow up was at baseline then weekly till 6 months. Both patients underwent maximized conservative management. RI brain, Carotid duplex, EEG were normal. Pain assessed on a verbal four-point scale, visual analogue scale and pain diary. No history of previous trauma, no association with nausea or vomiting. Upon  examination, bilateral tenderness over cervical facets. Normal Upper Limb reflexes, sensory and motor examination. Diagnostic block was positive. Medial branch ablative radiofrequency (RF) of the affected facet joint with 3rd occipital nerve were done. Transcranial Weberneedle Laser (TWNL) was applied using channels of Blue, Red and Green light emitting diode, for 12 sessions on the side with highest pain intensity. 
Case1 38-year-old female  with headache for 2 years. After RF neck pain and headache disappeared, the headache relapsed 2 weeks later with negative neck pain and tenderness. Headache was increasing in intensity with failed medications, so TWNL was applied with increasing power. 
Case2 45-year-old  female with headache for 15 years, mostly at night with bilateral masseter spasm. After RF neck pain relieved, but headache decreased in intensity and duration. TWNL was applied with constant power. 



Discussion: After RF, the neck pain improved by 90%, the headache improved in the 1st case for 2 weeks, while in the 2nd case by only 50%. After 3 sessions of TWNL, both patients showed 90% improvement. In 2nd week headache was fluctuating. By the end of the 12 sessions, the headache decreased 70% on the TWNL side, and disappeared on the other side. During 6 months, case 1 experienced 3 attacks of headaches, while case 2 had infrequent attacks with minimal masseter spam.

References:
1-	Joseph R. et al., Am Fam Physician. 2014;89(8):642-648.
2-	 International Headache Society. 2013;33(9) 629–808. 
3-	Gonzalez-Lima F, Barrett DW. Front Syst Neurosci. 2014;8:36.

 Learning points: TWNL can be a new noninvasive modality in resistant and mixed types of headache.

Transcranial low level weberneedle laser in the management of intractable headache : a case report