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Suggest treatment for severe headache and neck pain

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Posted on Tue, 7 Mar 2017
Question: history of concave fx of occipital bone 25 years ago whiplash atv rollover in August.20 year Hx of migraines without aura. 4 months neck pain and right shoulder( pain ac separation most likely) accompanied by daily headaches until I went to chiropractor Dec 27th. 4 hours later worst headache of my life improved but didn't stop. I woke up with bilateral weakness in arms and legs staggering drunk feeling couldn't open eyelids. Symptoms resolved over the next 2 days then developed extreme anxiety cervical dystonia EXTREME fatigue crying meltdowns dissociative feeling like everything was going really fast around me overwhelmed unable to use computer or phone screens for a month.
CT showed chronic are of cerebellum encephlomacia on left side that is not acute. ECG negative for A-fib. mother and maternal grandfather both dx with. Mother had 2 strokes in her 40's
doctor
Answered by Dr. Olsi Taka (4 hours later)
Brief Answer:
Suggested diagnose possible.

Detailed Answer:
I read your question carefully and I understand your concern.

It seems that your doctors have attributed most of those symptoms to a conversion syndrome, meaning that they were due to psychological stress which is manifested (converted) through physical symptoms. Whether that is possible...judging from that description it certainly is, the combination of those symptoms is atypical for a brain lesion. The history of brain trauma and migraine with aura also makes you more prone to such manifestations. The acute headache due to a blood pressure spike (though it is not mentioned whether blood pressure was measured during episode) may have served as a trigger. So I would also put a conversion syndrome as the primary hypothesis.

Whether there are other hypotheses... there is one which I wonder if it was explored to the end. You mention that acute headache started after a neck manipulation. Such manipulations in some very rare cases can cause a tear in a neck blood vessel, a dissection. That may manifest with intense headache in itself, may also be complicated with stroke and subarachnoid hemorrhage. Imaging would evidence it but it depends of what type and after how many days. A non contrast CT is not enough to evidence dissection, a CT angiography is necessary for that purpose, where contrast is injected to visualize blood vessels. Subarachnoid hemorrhage would be detected by simple CT, but depends also on how long after the headache it was done, if several days later it may be missed. Stroke is unlikely, a small stroke might be missed by CT but with the many symptoms you mentioned after related to different brain areas, it should be seen on CT (so even if there was a dissection at least a part of your symptoms still look psychological in nature).

So to conclude a conversion syndrome is the most likely cause but a dissection can't be excluded if no contrast CT of the vessels was done. The reassuring thing is that even in the eventuality there was a dissection the period with the higher risk had passed by now. If you want to push diagnosis to the end an angio MRI would be the most proper test at this stage to detect a remnant of a dissection.

I remain at your disposal for other questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (21 hours later)
a theory as to why daily headaches and migraines for 20 years would stop and the excruciating shoulder pain (huge swelling at ac joint) would completely stop after stroke incident?
I didn't know about most of the post and stroke symptomes until I looked them up after I experienced them(ie dissociative feelings, chronic fatigue, cervical dystonia) if it is psychiatric why do they match up?I did not take my blood pressure during the incident but I have had hypertensive episodes that it has sky rocketed under stress but on follow up with no meds returned to normal. Post incident it was in the mean range of 155/120 give or take and none of my homeopathic tricks would take it down.
The CT was done 7 days post stroke when the dystonia went crazy I noticed small cervical tics irregular starting sometime this summer after the wreck and thought it may have been a nerve or muscle twitch related to the whiplash. The whiplash symptoms with headache disappearing post stroke symptoms is baffling? I can't imaging why a neck and shoulder that caused me so much pain not to mention decades of headaches would stop.
doctor
Answered by Dr. Olsi Taka (12 hours later)
Brief Answer:
Read below

Detailed Answer:
Thank you for the additional information.

I am not sure what you mean by stroke incident, if you mean the recent episode I actually said that stroke was unlikely. To be honest I do not have an explanation about why your daily headaches and shoulder pain have stopped, tough to imagine a connection in particular for the shoulder pain, not any anatomical relation or common pain mechanism. For the headache one could at least hypothesize that prior headache was related to neck spine issues (cervicogenic headache) and neck manipulation improved spinal issue and hence reduced headache. Can't see a relation for the shoulder joint though, esp since there was swelling confirming that it was a joint issue and not referred pain from the neck.

As for the fact that you've looked up symptoms and they could happen in stroke that doesn't mean that is actually the cause. A stroke can manifest with any possible symptom, you name it. But we see the combination of symptoms together and whether they correspond to a certain brain area. Also when they correspond to a certain brain area, whether it is a brain area which is well evaluated by CT. In your case your combination of symptoms do not correspond to an area covered by a particular blood vessel. Also areas which would produce the symptoms you mentioned are in the anterior brain which is well evaluated by CT, a normal CT excludes that (no matter how many days after). So we evaluate the patient in entirety not separate symptoms, a separate symptom may be produced by many different conditions. That is why it is physicians who know how the human body and different systems work should make the diagnosis, not by looking symptoms in internet, could make you more confused. Psychiatric symptoms may be due to a stroke or other brain lesions such as tumor, trauma etc, but such cases represent only a minority, in most patients there is no such brain lesion. I hope I was able to clearly make my point.

As for the 155/120 value after that is pretty high, especially the diastolic pressure of 120, so it could be that it was even higher before.

A CT done after 7 days may not detect the subarachnoid hemorrhage or dissection I spoke about, a MRI should've been done (if that was suspected at all - perhaps the doctors thought that being no clinical signs it was not a possibility). However dystonia is not a manifestation of any of those conditions. It rarely is a manifestation of stroke either and even in those rare cases the areas responsible are well visualized by the CT, a stroke would've been detected.

Let me know if I can further assist you.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (3 hours later)
Thank you Doctor one last question (promise I hope)..... since December when I had the incident that I perceived as a stroke I've had the feeling I'm not myself I guess disassociated would be the best word. This was constant for weeks now I have periods where I feel like my self especially in the morning and for a few hours during the day here and there. What the heck is this strange fog thing? and does that mean I am going to have increased periods until I return to what I can only describe as my own personality and energy level. I sometimes wake up and feel "normal" like I did before the 27th but then it fades and I feel tired and flat again. You are awesome! Thank you
doctor
Answered by Dr. Olsi Taka (3 hours later)
Brief Answer:
Read below

Detailed Answer:
Hello again!

What many patients describe as brain fog is a complaint which is most commonly associated with stress and anxiety. Given the experience you have been describing till now I do not find it surprising for that to be your case. If given age is correct menopause with the hormonal changes it entails is a common contributor as well.

Of course there can be other causes, mainly metabolic or hormonal. For that reason if symptoms persist some blood tests would be advised (although perhaps most were already done) such as blood count, c reactive protein, glucose, liver and kidney function, electrolyte panel, thyroid function and vitamin B12 levels to check for other less likely possibilities.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Suggest treatment for severe headache and neck pain

Brief Answer: Suggested diagnose possible. Detailed Answer: I read your question carefully and I understand your concern. It seems that your doctors have attributed most of those symptoms to a conversion syndrome, meaning that they were due to psychological stress which is manifested (converted) through physical symptoms. Whether that is possible...judging from that description it certainly is, the combination of those symptoms is atypical for a brain lesion. The history of brain trauma and migraine with aura also makes you more prone to such manifestations. The acute headache due to a blood pressure spike (though it is not mentioned whether blood pressure was measured during episode) may have served as a trigger. So I would also put a conversion syndrome as the primary hypothesis. Whether there are other hypotheses... there is one which I wonder if it was explored to the end. You mention that acute headache started after a neck manipulation. Such manipulations in some very rare cases can cause a tear in a neck blood vessel, a dissection. That may manifest with intense headache in itself, may also be complicated with stroke and subarachnoid hemorrhage. Imaging would evidence it but it depends of what type and after how many days. A non contrast CT is not enough to evidence dissection, a CT angiography is necessary for that purpose, where contrast is injected to visualize blood vessels. Subarachnoid hemorrhage would be detected by simple CT, but depends also on how long after the headache it was done, if several days later it may be missed. Stroke is unlikely, a small stroke might be missed by CT but with the many symptoms you mentioned after related to different brain areas, it should be seen on CT (so even if there was a dissection at least a part of your symptoms still look psychological in nature). So to conclude a conversion syndrome is the most likely cause but a dissection can't be excluded if no contrast CT of the vessels was done. The reassuring thing is that even in the eventuality there was a dissection the period with the higher risk had passed by now. If you want to push diagnosis to the end an angio MRI would be the most proper test at this stage to detect a remnant of a dissection. I remain at your disposal for other questions.