Interview with Health and Healing
Headache and Neck Pain Following Trauma
Q- Dr. Matthews, do you see many patients at the Headache Clinic for headaches after minor bumps or neck strains?
A- Yes we do.
Q- What sort of problems are you seeing?
A- Well. let's talk about the sort of things that are emergencies first, and then we'll go over the problems that are not emergencies. You probably read about the tragic case of Natasha Richardson recently- the actress who died in a skiing accident after colliding with a tree? She suffered what is called an epidural hematoma. With a sudden blow to the skull, usually but not always with a fracture, there can be a rupture of one of the surface arteries of the brain. This is truly an emergency and requires immediate neurosurgical treatment, which is lifesaving if performed in time.
Q- Didn't she appear to be fine for awhile?
A-That's what I understand. That was a very tragic case. A period of alertness is actually typical, lasting perhaps up to a few hours. What happens is that the pressure in arteries is relatively high compared to brain pressure, and the expanding fluid will quickly fill up the space between the brain and the skull and start to push brain material away. Quite quickly, the pressure will become so severe that a herniation will occur- the brain will be pushed down into the spinal cord, or under the dividing membrane to the other side. This is essentially a fatal occurrance. Immediately before the final event, you may see a "blown pupil"; this results from pressure on the brain stem and is a sigh of impending brain herniation.
Q- I have a friend who has a dilated pupil during headache. Is she at risk for a serious condition?
A- The blown pupil of head trauma is a widely dilated pupil that doesn't react to light. Most people who develop pupil changes on one side, during a migraine headache, are suffering the effects of changes in the "fight or flight" reactions caused by headache. Interestingly, this can occur on only one side of the face. Rarely, pupil changes can be caused by a mass, most commonly an aneurysm, pressing on the nerve that controls the pupil- but these masses don't typically produce pupil changes only during headache. When there is an attack of pain, light or sound sensitivity, and nausea, without head trauma, the pupil dilation is almost certainly part of a migraine attack.
Q- What are the signs to look for that make you think someone is having an epidural hematoma emergency?
A- I think any heavy blow to the head should be observed in the emergency room. The trouble is, 999 out of 1000 of these injuries will be fine; one is actively bleeding from an artery and will need emergency surgery. I was recently at my son's lacrosse game and a young man was struck in the helmet with the lacrosse ball and briefly lost consciousness. After three minutes, I asked him orientation questions- how is the president? What year is it? What day of the week is it? He knew the first two, but missed the third. I advised his parents to transport him immediately to the ER. It turned out he was fine; and yes, the trouble I caused by advising them to go to the ER was the right thing to do. Watch for confusion, and also becoming sleepy. When you think about it, it is not normal to become sleepy when your head has been hit and you are in pain.
Q- Are there any other emergency problems after head trauma?
A- Subdural hematomas are more common in the elderly, who may have some atrophy of the brain and more fragile blood vessels. There is more "sagging" there, and more tension on the subdural veins. Subdural hematomas result from tears in the veins that bridge between the brain and the coverings under the skull. These low pressure bleeds are less likely to push brain material aside and cause herniation.
Q- How do you detect those?
A- In most elderly patients who have fallen, there may be a mild headache, and perhaps a little confusion. They may otherwise be fine, but are then seen in the ER and given a CAT scan of the head. The CAT scan may show the subdural hematoma, but sometimes it's normal. Can you think why this would be?
Q- I'm asking the questions here!
A- OK, sorry. The reason subdurals can be missed on initial CAT scan is that they bleed slowly- they are vein leaks, remember. So, if you take the picture too quick, you'll miss the slow leak. Later- hours, or even days or weeks- the unfortunate person will become confused, have difficulty with balance, or most ominously will become excessively sleepy. Most subdurals need neurosurgical treatment. There is another way that a CAT scan can miss a subdural repeated weeks later- the subdural begins to look more like surrounding brain tissue for awhile. Especially if there are equal subdurals on both sides, it's possible to repeat a CAT scan two weeks later and miss the problem again. What's the lesson here? Stop looking at the tests and start thinking about the patient!
Q- How about neck injuries?
A- Yes, there are cervical spine fractures; these are seen on regular old x-rays and are typically done in the ER because the consequences of missing a neck fracture are so severe. More rarely, there are arterial dissections in the neck which lead to headache; the inside of the carotid artery shears off; all of the flow to the brain comes from the other side. The dilation needed to carry this extra flow may havae many characteristics of migraine. (To make the whole thing a little more complicated, rarely a patient with severe migraine can suffer a carotid dissection, perhaps due to inflammation in the artery).
Q-Do minor bumps sometimes sometimes be the start of chronic headaches?
A- Yes, that's a fascinating subject. It's hard to know where to start,since it's a big subject too. But basically, it's clear that people who have a family history of migraine may begin to have headaches for the first time when they bump their head. These headaches usually respond to proper treatment for their headache type. Usually pain after minor trauma is treated with simple analgesics and muscle relaxers. If the pain is not improving by two weeks, or is not gone by one month, it is very important to be evaluated, as persistent headaches at one month tend to last for many months or even years without treatment, and may worsen.
Q- Can people who have low speed automobile collisions develop chronic problems with head or neck pain?
A- Basically, yes. I get to teach a little physics here- as you might remember from high school, Newton's Law says that F=MA. Remember that one? It says that the force F is equal to the mass times the acceleration. So, there is nothing at all in this equation of force that relates to speed; it's all how fast you are stopped, which is negative acceleration. Even without striking your head directly, the sudden movements back and forth on your neck can produce injury by the transmission of force through deceleration.
Q- What causes posttraumatic neck pain?
A- The muscles of the neck are responsible for making sure that your spine is not snapped, and they take their job very seriously. If there is a sudden movement, the neck muscles function like a shock absorber. They have a tendency to remember the shock and stay tense and prepared in case another injury should occur. This is a general physiological reaction; when you sit down on a chair and it crashes under you, the next time you sit on any chair your pulse will speed up. Your body remembers; the neck muscles have particularly good memories. Incidentally, another cause of neck trauma, quite common in people in their 20's, is neck strain brought about by jerking weights over their head at the gym.
Q- What symptoms does posttraumatic neck pain cause?
A- The most common are headaches and dizziness. In patients who are predisposed, there can be migraine attacks. The mechanism for dizziness production is interesting; when one side of your neck is in spasm and the other isn't, it gives you the feeling that your head is turning. Constantly correcting for this produces dizziness. It can be quite distracting, and some have difficulties concentrating while this type of dizziness is going on. My name for this is "cervicogenic dizziness". It is very commonly misdiagnosed as an ear problem.
Q- Any other posttraumatic pain syndromes you want to tell us about?
A- We see "sinus" pain after sinus surgery quite frequently. It happens like this; the person has a sinus infection behind a nasal obstruction, the obstruction is successfully removed at surgery and the patient feels fine for awhile. Then the very same pain comes back, and they go back to the surgeon thinking that they have another sinus infection just like the last time- only the examination is clear. So, they are sent over to the Headache Clinic. It turns out that any new headache, such as one triggered by jerking weights over the head at the gym, may be felt in the same place as the last headache. We have seen a number of patients who are completely convinced that their pain is in their sinuses to be immediately and completely relieved by treatment of their neck. There is a way to diagnose that a neck problem is causing your headache yourself. If you are someone who has a "sinus" headache, and it is relieved by pressure over the forehead, you might think that confirms the problem is in the sinuses. However, if you sit in a chair and press your head backwards into the chair- thus straining your neck extensor muscles- you may find that your facial pain gets worse. This means that the facial pain is actually coming from the extensor muscles in the back of the neck and under the skull. Try this on anyone who has a headache- it's less expensive than an MRI, and likely to be more useful. Remember, cervicogenic headaches respond poorly to migraine medication.
