Headache After MVA in Physically Active, Healthcare Professional

Abstract

HPI: 35 y/o F NP with hx of migraines, presented to the ED 1 day s/p MVA, c/o right-sided headache, nausea, photophobia. The patient went off the road at 30 mph, hitting a snowbank. She had a mild headache after the accident, saying her head whiplashed but denied hitting her head, or LOC. She took an ibuprofen but woke up the following morning with the worst headache of her life, prompting ED visit. Pertinent negatives: No retrograde amnesia, phonophobia, blurred vision, eye pain, hearing loss, tinnitus, neck pain, extremity weakness, paresthesia, dizziness. In the ED, patient was told her eye dilated funny, but otherwise normal exam. CT head was negative. GCS 15. Symptoms improved with prochlorperazine, diphenhydramine. She followed up in the office 2 days later, with continued symptoms. Office SCAT2 scored 52. She was diagnosed with post-concussion syndrome, and treated supportively. Over the next several months, patient developed diplopia, vertigo, neck pain, fatigue. EXAM: Vital signs were stable and afebrile, well-developed, AAxOx3, anxious. NCAT. Pupils were equal, round, and L pupil was sluggishly reactive to light. EOMI Visual acuity: OU20/20, OD/OS20/25. AROM/PROM of head and neck were normal. No ptosis, proptosis. CN 2-12 intact. Romberg test negative. Motor strength 5/5 UE & LE. Sensation intact. Subsequent office visits revealed R neck pain to palpation, asymmetry along R levator and R trapezius muscles, with reduced range of motion. DDX: Post-concussive syndrome, BPPV, chronic migraine with aura, CN injury, malignancy/tumor TESTS/RESULTS: CT head (ED) negative. X-ray cervical spine AP/lateral negative. Non-contrast brain MRI negative. She received OMT for neck pain with mild improvement. While working with OT, patient was noted to have horizontal saccades on lateral gaze along L eye, with lateral deviation of L eye. She was referred to neuro-optometry. She was diagnosed with CN3 palsy. DX: Partial oculomotor (CN3) nerve palsy secondary to whiplash from MVA TX & OUTCOMES: Tx: Optometry rehab with vestibular exercises, prism therapy, OMT, TP injections, PT/OT; Sumatriptan, amitriptyline, melatonin. 17 mo s/p MVA, pt continued to have intermittent headaches, light/noise sensitivity, trouble focusing. Symptoms have improved and pt resumed training for local 5K, which she completed. She is not at baseline.