A Head Full of Pain A 54-year-old woman sat quietly as the chiropractor worked her neck the way she had so many times before. Suddenly a pulsing, whooshing noise thundered in the woman's left ear. It reminded her of the sound of her heart when she had an echocardiogram years earlier - but this was much, much louder. The chiropractor stopped immediately, but the noise did not. The Patient's Story It pounded away at her ear - rhythmic, loud and unrelenting. The noise was always present but seemed to get worse when she lay down or turned her head a certain way. Usually it was just annoying, but sometimes it grew so loud she had trouble hearing other people speak. Still it seemed manageable, at least at first. A few weeks later, she suddenly felt as if she had been hit on the left side of her head with a brick. The pain was blinding. She had to leave work to lie in a darkened room. It was probably a migraine, her doctor told her, giving her a prescription for a drug called Zomig and ordering an M.R.I. of her brain. Neither the medicine nor the scans were helpful. The headache lasted two more days. After that, the occasional migraine would come and go; the whooshing noise remained constant. The Specialists Her doctor sent her to a neurologist, who ordered a different M.R.I., this one of the brain's arteries, to look for any damage from the chiropractor's maneuver. When the test came back normal, he diagnosed tinnitus (the perception of sound in the head or ears - from the Latin word tinnire , meaning to ring) and migraine headaches. An ear-nose-and-throat specialist gave her a hearing test, which revealed mild hearing loss. The E.N.T. then ordered an M.R.I. of the venous system of the brain. It, too, was normal. A second E.N.T. reviewed the studies and also suggested a diagnosis of tinnitus and mild hearing loss; he added eustachian-tube dysfunction. None of the specialists had any advice on how to get rid of the noise or the headaches. Self-Diagnosis A few months later, the patient read about a disease called fibromuscular dysplasia (FMD), an unusual disorder in which the walls of arteries narrow and limit blood flow to essential organs - usually the kidneys or brain. Could she have FMD? She made an appointment with Dr. Jeffrey Olin, the director of vascular medicine at Mount Sinai Medical Center, in New York, who was quoted in the article. Olin arranged for detailed imaging of the carotid arteries, the vessels that bring blood from the heart to the brain. As the technician was injecting contrast dye into her vein, the patient suddenly felt an icepick of pain shoot from the top of her skull past her ears down to her clavicle. It was all she could do not to scream. It was worse even than the migraines she continued to get. Olin was immediately concerned. Could the slightly increased pressure caused by the injection of contrast have torn a fragile segment of the patient's carotid artery? He saw no evidence of a tear, but the images showed that her carotids were not normal. They twisted and turned on their way from the heart to the brain. And on the left, where the pain, headache and noise originated, the artery made a 360-degree loop. Olin knew that this kind of abnormality could cause tinnitus and migraines. But he could not explain the pain that occasionally knifed through her face to her neck. Looking for Causes A second neurologist thought the pain might be from injured neck muscles. He prescribed a muscle relaxant. It didn't help. A vascular surgeon gave a diagnosis of temporal arteritis - inflammation of the arteries of the head, eyes and face, which can cause blindness and strokes. She was started on a high dose of steroids and referred to a rheumatologist. The rheumatologist ordered an ultrasound and then a biopsy of the artery. Both were normal and the patient was weaned off the steroids. The pain and whooshing remained. Meeting the Patient Last August, the patient came to my office in Waterbury, Conn. Could I figure out the cause of the pain she'd had for the past two and a half years? she asked. She used to sky-dive, hike and climb mountains. Now simply going up a flight of stairs could cause excruciating pain in her head. A Process of Elimination In medicine, it is essential to rule out diseases that can kill, and then move on to those that may only make you wish you were dead. The patient didn't have a tumor. And none of the scans identified a tear. Still, given her story, I thought it was pretty likely that the chiropractic maneuver had caused some minor trauma, and that the injection of contrast had as well. Could these injuries be contributing to the pain? When I examined her, there was a tenderness in her neck over her left carotid artery. Could she have carotidynia (from Greek, meaning painful carotid), an unusual but well-described condition caused by inflammation of the tissues of the carotid artery? The cause is unknown, but it is most frequently seen in patients with migraines and can usually be treated with the medications used to prevent those headaches. I started her on one and asked her to come back in a few weeks. She was hopeful, and so was I. An Incidental Finding