Head and neck pain in the elderly

Chapter 30 Head and neck pain in the elderly



Case 30.1



1. List the possible causes of Jane’s neck and interscapular pain. Based only on the history, do you think that her symptoms are more likely to have a mechanical or a non-mechanical cause? Justify your answer.

Possible causes are:


a ischaemic heart disease

b vertebral pathology

c musculoskeletal dysfunction (mechanical).

It is more likely non-mechanical in nature, as the pain is precipitated by exertion, and relieved rapidly by rest. It is important to consider vascular insufficiency as a cause in these circumstances. Although a mechanical problem may be aggravated by walking, it would also be aggravated by movement of that specific area of the body.


2. What type of drug is prazosin hydrochloride?

Prazosin hydrochloride is an alpha adrenergic antagonist, which is used to treat hypertension.


3. What type of ‘hormones’ do you think Jane was referring to?

Hormone replacement therapy — it may have been oestrogen alone, or in combination with progesterone.


4. What parts of her history may be indicative of anxiety?

Palpitations, hearing ‘throbbing’ in her ears, sleep disturbances, irritability, past episode of shingles (may be precipitated by stress).


5. What do you need to examine in this patient?

Full physical examination, but specifically:


• vital signs

• cardiovascular examination, including peripheral pulses, carotid arteries and renal arteries (if angina is suspected, you will need to assess for the possibility of other areas of vascular involvement)

• musculoskeletal examination of neck and upper back.

6. What information can you obtain from these findings? Can you narrow your differential diagnosis?
• Blood pressure is still slightly high, even with the use of medication.

• There is evidence of possible anaemia, due to the pallor of her conjunctiva, and a pulse rate which is at the upper range of normal.

• The shift in the apex beat suggests left ventricular enlargement.

• The tightness of trapezius and scalenes is a common finding and may be of little significance. However, if the pains experienced in the interscapular and neck were related to postural changes and other movements in addition to walking, it could be an explanation for her pain.

7. Does the patient need to be referred? If so, what investigations are required? Why? What would you expect, based on the physical examination findings?

Yes, Jane needs to be referred. Jane requires:


• an Electrocardiogram (ECG) (resting and exercise) for the possibility of ischaemic heart disease

• a chest X-ray, for cardiomegaly

• full blood count for the investigation of possible anaemia

• risk factors for ischaemic heart disease should also be performed, including cholesterol, triglycerides, LDL and HDLs.

Expected findings would be:


• ECG: pattern of ischaemia

• chest X-ray: enlargement of heart shadow

• full blood count: reduced haemoglobin

• lipids: uncertain.

8. What is your final diagnosis, based on these results? Justify your answer.
• Ischaemic heart disease — angina (ECG findings).

• Left ventricular hypertrophy (chest X-ray appearance).

• Macrocytic anaemia (decrease in haemoglobin and increase in mean cell volume).

• Hyperlipidaemia (increase in triglycerides, cholesterol and LDL, plus a decrease in HDLs).

9. Do you think that these conditions are related in some way?

They are most likely related.


• Jane has a number of risk factors for ischaemic heart disease.
image a family history of vascular disease and heart disease.

image she is a smoker

image she has hypertension

image hypercholesterolaemia, and an unfavourable ratio of HDLs to LDLs.

• Her cardiomegaly is probably the result of sustained hypertension — a common occurrence.

• Her anaemia may be the ‘critical event’ (the ‘final straw’) which has resulted in the development of her symptoms. The pain in angina is due to the stimulation of pain receptors by metabolites such as lactic acid, which have formed as a result of anaerobic respiration. Usually this only occurs when the needs of the heart for oxygen are greater than the availability of oxygen provided. Anaemia is characterised by a decrease in the amount of oxygen available to tissues. Thus, the development of anaemia can exacerbate any pre-existing myocardial ischaemia.

10. Are any further investigations required?

The cause of her macrocytic anaemia needs to be found. Folate and Vitamin B12 levels in blood need to be assessed.


11. What do you believe to be the cause of her neck and interscapular pain?

Angina: interscapular and neck pain in ischaemic heart disease is not uncommon.


12. What is the most likely cause of her anaemia?

Dietary insufficiency — she has recently become vegetarian.



Case 30.2



1. Using only this information, list the possible causes of June’s headache. Justify your answer.

The risk of a serious disorder being the underlying cause of a headache is much greater in patients over the age of 65 years. The onset of a new headache in the elderly should therefore raise the suspicion of serious pathology such as space occupying lesions, temporal arteritis, or cerebrovascular disease. Likely differentials and important disorders not to miss for a new-onset headache in this patient should include:


• Primary headaches:
image migraine

image tension.

• Secondary headaches:
image neoplasm

image cerebrovascular disease

image temporal arteritis (aka giant cell arteritis)

image trigeminal neuralgia

image systemic disease

image exertional headache

image pain from disorders of the skull, cervical spine, eyes, ears and nose.

Given the location and type of pain, the lack of other symptoms, the lack of relief from paracetamol and the past good health of this patient, the most likely cause of her headache would be temporal arteritis.

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Head and neck pain in the elderly

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