Case Study: Refractory Chronic Headache in an Adolescent with a Complex Multi-System History

Case at a Glance

A 15-year-old male presents with a 2.5-year history of debilitating chronic headaches and fatigue following a concussion. His complex diagnostic journey has included post-concussion syndrome, tick-borne illnesses, chronic sinusitis, and a symptomatic arachnoid cyst. Despite targeted treatments for each, including neurosurgery, his primary symptoms persist and have worsened, posing significant challenges to his daily functioning and education.

Patient's Story

The patient is a 15-year-old male who, for the past 2.5 years, has been suffering from persistent, severe headaches and fatigue that have profoundly disrupted his life. Prior to symptom onset, he was healthy and active, with no history of smoking, alcohol, or drug use. The condition has forced him to limit cognitive tasks, such as schoolwork, to less than an hour at a time and has severely impacted his sleep patterns and overall quality of life.

Initial Assessment

The patient's symptoms began after a skiing accident in February 2023, which resulted in a concussion. He immediately developed consistent headaches, balance difficulties, changes in handwriting, and joint pain, predominantly in his knees. He was initially managed with rehabilitative physical therapy for several months, but his constellation of symptoms did not resolve.

The Diagnostic Journey

The patient's journey involved multiple specialists and a series of diagnoses. In June 2023, he was diagnosed with Lyme disease, Bartonella, and Babesia. He completed a year-long course of antibiotic therapy, with subsequent bloodwork confirming resolution of the infections. Concurrently, in August 2023, a vision specialist identified ocular misalignment, for which he received vision therapy for six months and wore corrective prism glasses for a year.

Despite these interventions, symptoms persisted. An MRI in October 2023 revealed significant sinus disease. An ENT evaluation confirmed a severely deviated septum and chronic sinusitis, leading to corrective surgery in March 2024. During this period, environmental factors like mold were ruled out, and alternative therapies such as osteopathy and acupuncture provided no relief.

A diagnosis of Post-COVID-19 condition was made in the summer of 2024. A neurological consultation in June 2024 led to trials of multiple prescription headache medications, including ubrogepant (Ubrelvy), none of which were effective.

A repeat MRI in December 2024 identified a 3 cm arachnoid cyst posterior to the left temporal lobe, which had been present but unreported on the October 2023 scan. In January 2025, he underwent successful neurosurgical resection of the cyst. The surgery resolved his joint pain and slightly improved his balance, but paradoxically worsened his headaches, which now became bilateral instead of being confined to the left side. He also developed new-onset neck pain.

Post-surgically, trigger point injections administered by his neurologist failed to provide pain relief. Follow-up with a vision specialist specializing in post-TBI and Lyme-related issues revealed ongoing perceptual deficits, necessitating new, updated prism glasses. Ongoing investigations include a CT scan and sleep study to evaluate enlarged adenoids and persistent sleep disturbances.

Final Diagnosis

The patient has multiple treated and ongoing diagnoses, but a single unifying cause for his primary complaint remains elusive. The working diagnoses are:

1. Intractable Chronic Daily Headache, likely multifactorial (Post-concussion, Post-infectious, Post-surgical).
2. Post-Concussion Syndrome.
3. Post-COVID-19 Condition.
4. Central Sensitization Syndrome.
5. Sleep-Wake Cycle Disorder.

Resolved diagnoses include Lyme/Bartonella/Babesia, Chronic Sinusitis, and Arachnoid Cyst.

Treatment Plan

The patient's current regimen is focused on symptom management:

• Pharmacotherapy: Leucovorin (for folate metabolism support), Trazodone and a melatonin/valerian root supplement for sleep initiation, Tramadol as needed for pain (limited to 3 doses/day), and montelukast with fluticasone nasal spray for seasonal allergies.
• Therapy: Ongoing specialized vision therapy.
• Awaiting Results: Further management will be guided by the pending results of his head/neck CT scan and sleep study, which may indicate a need for adenoidectomy.

Given the refractory nature of his pain, the clinical team is considering escalation to advanced pain management strategies.

Outcome and Follow-up

To date, the patient remains significantly debilitated. While surgical interventions have resolved specific issues like joint pain and sinus disease, his primary complaints of headache and fatigue have not improved and, in some aspects, have worsened. His functional capacity, especially for cognitive tasks, is severely limited. Follow-up is scheduled with Neurology and ENT. Due to the failure of multiple treatment modalities, a consultation to discuss the potential utility of advanced interventions, such as ketamine infusion therapy for refractory chronic pain, has been suggested as a possible next step.