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Chronic R Upper Cervical Pain/Head Aches

Exit forum ID Forum Discussion Chronic R Upper Cervical Pain/Head Aches

This topic contains 2 replies, has 2 voices, and was last updated by   Jamie Hansen January 6, 2020 at 8:09 am.

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  • #8858

    Jamie Hansen
    Keymaster

      Hey everyone,

      Any and all input will be very helpful with this case:
      I have seen her now 10x and reaching the end of care. I want to make sure that I have lined up all my ducks with her and that i am not missing anything in my though process.

      1st Order:
      F, 54yr
      SX Loc:
      Right base of skull, Lat Neck and intra scap
      SX Quality:
      Achy, Throbbing
      SX Intensity:
      Avg; 7/10, Worst 10/10 happens ~1-2x/wk, Best 2/10 1x/month-ish
      P+:
      Not sleeping, CPU, Extension, dietary (wheat, dairy corn)
      P-:
      Ice, Essential Oils, NSAIDS if needed

      Initial DX Hypothesis:
      Lower disc
      DDD
      Emotional/Stress
      Auto-Immune (clean blood work)
      Working DX:
      2017 C5-6 Annular Tear (MRI)
      DDD
      Adhesion
      Emotional/Stress

      EXAM:
      UCF:15 currently at 22
      CF: 58 currently at 61
      CTF:70 Currently at 85
      ROT: R 65/72% currently 75/83%
      L 64/70% Currently 78/86%

      Currently some Mild adhesion at R base of skull and LS and NR. Treatment of her right c2/c3 jt capsules reproduce CCX with 10/10 pain

      2nd Order:
      Onset: 30+ yr as left sided menstrual head aches. Those have since stopped currently the HA are constant, and daily.

      INFO OF NOTE:
      A) From 2016-2017 and again from 2017-2018 she saw 2 different upper cervical specialists in that time she was treated 2-3x/wk over the course of a yr. in each case She started crying while expressing this, but noted that she would leave in so much pain, she even developed vertigo during those 2 yrs. The pain they caused her and there inability to explain why she was in more pain and did not return her calls left her angry, scared and feeling victimized. She is traumatized from this experience.
      B) She had a trauma with her youngest daughter (now 19) that when she was an infant she stopped breathing since than, she has not been able to sleep a full nights sleep and wakes up nightly with severe anxiety.
      C) She is currently separating/divorcing her husband of 30+ yrs. he is still living in the house and again she has not mentioned this to her youngest daughter.
      D) MRI showed mild narrowing of right carotid Art. This caused massive amounts of stress and anxiety as this is her symptomatic side.
      E) Palpation of the right C2 and C3 TP creates a 10/10 sever pain stating “thats my headache, thats the pain why isnt it going away”

      I used the Fast MAP and its a 65% psychological problem, 25% MS, 25% structural 40% metabolic.

      I want to spend the next 2 visits cleaning up the residual structures that have some mild adhesion. She has consistently sustained 25-30% permanent relief and i wanted to know if there is anything else i can help her with?

      I recommended:
      a) vascular dr to ease her anxiety about her carotid
      b) stress management (yoga, meditation)
      c) her diet is “clean”
      d) calling BBB on those dr’s that “harmed her” she wont but it might help her
      e) ??

      As always thank you all for your continued help and input.

      #8874

      Seth Schultz, DC
      Participant

        Her % improved matches her FastMap score, trying to squeeze more treatment may not be in her best interest. The vascular and stress components of her problem takes front seat. Is she receiving treatment for those complaints as well?

        #8876

        Jamie Hansen
        Keymaster

          Thanks Seth for the input/questions:
          No she is not seeking help in professional manner. She is hesitant/resisting. I spoke to her about her issues regarding her daughter and will follow up about the other issues.
          Next visit i will again check in and see how she is doing. I mentioned that we are close MMI and approaching maintenance. Curious to see how she reacts.

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