CASE FILE | Salvatore "Sal" Ficara

Pressure /heaviness /tightness

Bilateral occipital, worse left

A 12-year journey—documented to uncover patterns, triggers, and what actually helps.

Primary concernPressure & heaviness

Intensity (7-day avg.)7.7 / 10High

Duration (typical)Not logged

Recent trendSlight increase

Your Insights

A timeline of patterns, progress and key moments.

TimelineHighlights

Start

2014
Symptom onset

Symptom history

How it began

2014

Onset

Pressure, heaviness and tightness

Pattern

What we're seeing

Chronic

~30 symptom
days per month

14 severe

Common triggers

What tends to set it off

Mechanical cervical load
Sleep / static neck position
Neck-jarring impact
Air travel descent (into PHL)

+ 2 more

Interventions

What we've tried

Botox PREEMPT 200uRound 3 on 7/2/26.

AcupunctureQueued

Severity trend

The big picture

8.5–10/10

Severe episodes

→

Continue

Explore details,
log updates,
and next steps

Open full log diary

Hypothesis

Competing explanations for the same symptoms, weighed by the evidence for and against each. Hover a line for context; click a card to focus.

Working diagnosis

Chronic migraine, intractable

With status migrainosus · NDPH phenotype

ICD-10 G43.711Penn Neurology · Dr. Kaiser

EVIDENCE FOR

Photophobia

Also explained by trigeminocervical convergence

Severity & chronicity

Non-specific — fits any chronic pain syndrome

Partial Botox response

Also explained by needling effect on muscle

EVIDENCE AGAINST

Ajovy (CGRP mAb) — 6 mo no benefit

Triptans ineffective

Gepant (ubrogepant) ineffective

Multiple migraine preventives failed

Constant, not episodic

WORKING CONFIDENCE

40%

Patient's hypothesis

Cervicogenic, C2–C3 facet-mediated

With chronic myofascial / suboccipital component

ICHD-3 11.2.1 criteriaPatient synthesis · supported by Bischof CRNP note

EVIDENCE FOR

Decade-long 100% load-dependent worsening

Shrugs, squats, running reliably reproduce. Meets ICHD-3 cervicogenic criterion.

GON + LON block produced NO pain relief

Anesthesia confirmed in distribution — argues against classic occipital neuralgia. Pain generator is deeper.

Bischof CRNP note (4/9/2026)

"Benefit right after injections seems to be from acupuncture effect of the needle releasing tight muscle."

Straightening of cervical lordosis on MRI

Radiologic signature of chronic suboccipital muscle guarding.

Pain reliably worst on waking

Improves through day with activity. Classic mechanical facet/disc pattern.

C5-6 right central HD flattening cord

Stable across 2022 & 2023 MRIs (Vaccaro/Rothman).

Palpable tender cord behind left ear

Patient-identified myofascial finding.

EVIDENCE AGAINST

Penn dismisses C4-C7 as "too low" to refer

Reasonable for direct neuro referral. Does not address secondary muscle splinting or compensatory upper-cervical loading.

Upper cervical never imaged with focus

C0-C3 + atlanto-occipital + atlantoaxial joints not yet evaluated.

Third occipital nerve never tested

The diagnostic test that would confirm or refute this. Never performed.

WORKING CONFIDENCE

78%

STATUS

RULED OUT

Classic greater occipital neuralgia

Failed bilateral GON+LON anesthetic block 5/29/2025

Structural intracranial pathology

MRI brain 6/1/2024 — normal

Vascular — aneurysm, stenosis

MRA head 6/1/2024 — normal

Venous outflow obstruction / CSVT / IJV stenosis

CT venogram 10/27/2025 — normal

NOT YET RULED OUT

Idiopathic intracranial hypertension

→ LP discussed, never performed

Upper cervical (C0-C2, C2-C3) joint/ligament pathology

→ Never imaged with focus

Sleep-disordered breathing

→ Sleep study referral discussed, never pursued

Timeline

The history in one column. Starred markers are the datapoints that should move the working diagnosis.

~2014

Onset

Woke one morning with constant occipital pressure. Has never resolved.

Pre-2024

Prior workup

Seen by 4 prior neurologists incl. Lotkowski. Jefferson Neurosurgery (Zarzour) for chronic neck pain. C-collar trial. PT × 2 ineffective.

2/27/2022

★ KEY DATAPOINT

MRI cervical spine

C4-5 disc bulge · C5-6 right paracentral HD abutting cord · C6-7 left HD with moderate left foraminal stenosis.

2/4/2022

MRI brain w/wo

Motion-degraded. Likely cerebellar tonsillar ectopia, not impeding CSF flow. No significant structural findings.

4/18/2023

★ KEY DATAPOINT

MRI C-spine · Rothman (Vaccaro)

Right central HD at C4-5 · right central HD at C5-6 flattening cord · STRAIGHTENING OF CERVICAL LORDOSIS. Top-tier spine workup.

4/19/2024

Penn Neurology — initial consultation

Dr. Eric Kaiser. Dx: NDPH vs chronic migraine. Started nortriptyline + rizatriptan PRN.

6/1/2024

MRI brain + MRA head

NORMAL. No acute abnormality. No stenosis, occlusion, or aneurysm.

8/2/2024

Penn follow-up

Brief 2-wk improvement window. Sleep questioned (wakes 3-6×/night). Continue nortriptyline.

11/4/2024

Zeccardi CRNP follow-up

Symptoms unchanged. Reaffirm Ajovy plan.

3/21/2025

Onifade + Kaiser — Ajovy fail

3 mo Ajovy = no improvement. Schedule occipital nerve blocks.

5/29/2025

★ KEY DATAPOINT

Bilateral GON + LON block · Zeccardi

2cc lido 1% + 8cc bupiv 0.5%. Star pattern at each occipital notch + 1cc LON. NO pain relief. Only effect: colors vibrant 12hr.

10/2/2025

Scott + Kaiser follow-up

Ajovy discontinued. Patient distressed; flying worsens pressure. Botox PREEMPT started. LP considered.

10/27/2025

CT head + neck venogram

NORMAL. Ruled out dural sinus / IJV stenosis / CSVT.

1/15/2026

Botox Round 1 · Bischof

200u PREEMPT. Minimal benefit overall.

4/9/2026

★ KEY DATAPOINT

Botox Round 2 · Bischof

4 days great relief post-injection, then 3 good days. KEY NOTE: "Benefit seems from acupuncture effect of needle releasing tight muscle." Acupuncture referral.

Apr–May 2026

★ KEY DATAPOINT

Self-administered load test

After multi-year exercise break, resumed shrugs/squats/pull-downs/rowing/running. Headaches markedly worse than they had been in months. Clean natural experiment.

7/2/2026

Botox Round 3

SCHEDULED.

~Aug 2026

Kaiser re-evaluation

SCHEDULED. Plan to present full hypothesis & request TON block.

Treatments

What's been tried, what's active, and what's next — with how each one worked out.

TreatmentClassOutcomeNotes

Amitriptyline

TCA

Failed

Helped IBS only. AM grogginess. Discontinued.

Nortriptyline

TCA

Failed

Ineffective. Discontinued.

Topiramate

Anticonvulsant

Failed

Ineffective.

Ajovy (fremanezumab)Big against migraine theory.

Anti-CGRP mAb

Failed

6 mo. No improvement. Discontinued 10/2/2025.

Rizatriptan 10mg

Triptan

Failed

Tried a few times. Ineffective.

Ubrogepant

Gepant

Failed

Ineffective.

Naproxen 500mg

NSAID

Partial

Reduces pressure, does not resolve.

Flexeril 10mg

Muscle relaxant

Partial

Partially effective.

Tylenol PRN

Analgesic

Partial

Limited efficacy.

Alprazolam (one-off)

Benzodiazepine

Partial

Full symptom-free morning. Not sustainable.

Physical therapy × 2

Non-pharm

Failed

Both generic — not upper-cervical specific.

C-collar

Non-pharm

Failed

Tried as recommended. No sustained benefit.

Bilateral GON + LON blockArgues against occipital neuralgia.

Interventional

Failed

5/29/2025. NO pain relief. Colors vibrant 12hr.

Botox PREEMPT 200uRound 3 on 7/2/26.

Interventional

Active

Partial — 4d post-injection relief, then 3 good days. Provider notes mechanism may be needling.

Acupuncture

Integrative

Queued

Referral active. Directly tests Bischof's needling hypothesis.

Triggers

Patterns that line up with flares, ranked by how strongly they show up.

Mechanical cervical load

100%

Shrugs, squats, pull-downs, rowing. Decade-long 100% reproducible.

Sleep / static neck position

95%

Worst on waking. Wakes 3-6×/night.

Air travel descent (into PHL)

70%

Severe stabbing last 15min of descent. Not Chicago.

Alcohol

50%

Skipped meals

50%

Neck-jarring impact

90%

Jogging, running. Exacerbated by lordosis straightening.

Next steps

Bring this list to your next appointment. Check items off as they're scheduled or completed.

Tier 1 · Highest priority

Third occipital nerve (TON) / C2-C3 medial branch block

The test the workup has been missing. GON block was negative; TON evaluates a completely different pathway. If positive → RFA opens up.

→ Request at Aug Kaiser RPV

Repeat cervical MRI — focus C0–C3

Last C-spine MRI 4/18/2023. Check for progression, focus on upper cervical alignment, atlanto-occipital/axial joints, suboccipital muscle quality.

→ Order at next visit

Tier 2 · Therapeutic & diagnostic

Ultrasound-guided GON hydrodissection (5% dextrose)

Anesthetic negative doesn't fully rule out fascial entrapment. Hydrodissection mechanically separates nerve from fascia.

→ Refer to Interventional Pain

Suboccipital trigger point injections

Directly tests Bischof's myofascial hypothesis. RCPM / obliquus capitis / splenius capitis. Low-risk, immediately informative.

→ Refer to Interventional Pain

Acupuncture trial (Integrative Medicine)

Pursue. Find practitioner experienced with cervicogenic / suboccipital trigger points.

→ In progress

Tier 3 · Worth discussing

Upper-cervical-trained PT

Mulligan SNAGs, suboccipital release, deep neck flexor activation. Generic PT has failed twice.

→ Ask Kaiser for referral

Oral CGRP gepant trial (atogepant/rimegepant)

Different mechanism than Ajovy mAb. Worth asking even within migraine framing.

→ Discuss with Kaiser

Sleep study

Wakes 3-6×/night. Discussed but never pursued. Untreated SDB drives morning headaches.

→ Request referral

Lumbar puncture

Discussed 10/2/2025 to evaluate intracranial pressure. Not yet done.

→ Revisit decision

Care team

Penn Neurology — Primary

Eric Kaiser, MD/PhD

Working dx: chronic migraine intractable

Penn Neurology — Botox

Holly Bischof, CRNP

Authored the key 4/9/2026 needling-mechanism note

Penn Neurology — Procedures

Sara Zeccardi, CRNP

Performed GON+LON block

Rothman/Jefferson — Spine

Alexander Vaccaro, MD

Ordered 4/18/2023 C-spine MRI

Primary Care

Robert B. Ocasio, MD

Inspira Medical Group, West Deptford

Referring PCP (original)

Kristen Trom, MD

Referred to Penn in 2024

SALVATORE "SAL" FICARA · CASE FILE · May 12, 2026END OF DOCUMENT ↘