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The sneaky pain of arterial tears

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years.

Neck artery tears (cervical artery dissection) can be sneaky, sometimes causing only pain.See Arnold 2006, Kerry 2009, Maruyama 2012 Some people with neck pain and/or headache may actually have damaged neck arteries, and are at a high risk for stroke. There are two arteries in the neck that do this:

  1. The big high-pressure carotid artery.
  2. The small and often tortuous vertebral artery, which threads its way through a series of holes in the side of the spine.

This is the stuff of hypochondriac nightmares, because it’s such a serious problem that can almost perfectly mimic such an ordinary, common problem. But it’s not a perfect mimic. The pain is usually dramatically bad and weird. Arnold et al: “Pain was different from earlier episodes in all but one case [of 20].” Maruyama et al:

All but one patient [of seven] with migraine considered the pain to be unique and unusual compared with previously experienced headache or neck pain episodes. Nevertheless, pain was often interpreted initially as migraine or musculoskeletal in nature by the patient or the treating doctor.

Everything else about the pain is less predictable.Arnold “Pain topography, dynamics, quality and intensity were heterogeneous.” In other words, there are almost certainly some cases that are effectively impossible to distinguish from ordinary neck pain and headache. Many but by no means all cases are:

And then of course there could be other, stranger symptoms. If some cases cause only pain, but most cases have more traditional symptoms of arterial dissection, then there are surely some stuck in the middle: a lot of pain, and a few subtle hints of the more serious problem. Any neuro-ish symptoms in combination with severe, strange pain should jack the clinical suspicion up as high as it can go, and it should be treated like an emergency.

Specifically, what else might be going on? First, keep the F.A.S.T. signs of stroke: face drooping, arm weakness, speech difficulty… time to call 911! Non-stroke (or pre-stroke) symptoms associated with artery tears: neck swelling, reduced vision and/or visual disturbance, constricted pupil, drooping eyelid, pulsatile ringing in the ears, decreased taste.

I’ve updated my articles on tension headaches and scary causes of neck pain with this information, and of course my full neck pain tutorial. It’s also strongly relevant to the potential harms of chiropractic adjustment of the neck: what if you sought chiropractic care for neck pain, and the pain was the only symptom of a damaged artery? Spinal manipulative therapy in that situation would be crazy dangerous.

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