As a specialist in relieving chronic pain, many of my patients come to me by way of referrals. That's how I met the man whose headache kept coming back. Ever since he had retired to Florida from the Northeastern United States seven years earlier, he would get a headache every night as soon as he put his head on the pillow. Though he sought relief from the excruciating pain at a number of pain clinics in Dade, Broward, and Duval counties, the headaches persisted.

When he moved to St. Augustine he went to the family practice outpatient clinic of the Mayo Clinic to see if they could help. After trying the Mayo Clinic, a friend of his referred him to my office.

When he came for his first consultation he explained how he had come to dread going to bed since it was simply by getting into bed and lying back that would prompt the terrible pain in his head. I could hear the frustration in his voice as he went through his story, which he had undoubtedly told countless times before to other doctors.

In reviewing his medical history I could see that he had been through exhaustive investigations and had undergone different injection procedures of the neck that should have relieved the pain, including epidural steroid injections and cervical facet blocks, but with no success.

Preliminary Diagnosis: Given the fact that none of the treatments performed by the other pain clinics--all of them reputable and some with world-class credentials--relieved the pain, I performed a full examination, including a radiological investigation, to rule out the most serious causes of headaches. Based on the results, I made a preliminary diagnosis of Greater Occipital Neuropathy.

Initial Treatment: I performed a greater Occipital nerve block on the right side and the patient did experience relief initially, which supported my preliminary diagnosis of Occipital neuropathy. Following the procedure I recommended a regiment of physical and medical therapy.

Initial Results: Despite the fact that the procedure had provided temporary relief from the headaches, and the patient was adhering to the treatment plan, the headaches returned a few weeks later. At this point the patient was quite discouraged. He had come to me, in his words "at the end of his rope," and now he didn't know where to turn.

Next Steps: Despite the setback I was determined to do whatever I could to help relieve his pain. Sometimes the best course of action is a further referral.

Dr. Gabor Racz, a man from whom I have had the privilege to learn from while attending seminars in Boston and Phoenix, is one of the best pain practitioners in the world. He is currently president of the World Institute of Pain in Lubbock, Texas. I contacted Dr. Racz and explained the case. Dr. Racz agreed to see the patient, who without hesitation made the arrangements to travel to Lubbock.

Results: Dr. Racz's initial treatment was very successful and relieved his pain. He continues to see Dr. Racz. My patient has become a friend, and occasionally drops by the office to say hello and stay in touch.