Whiplash headache is transitory worsening of a pre-existing primary headache.

Acute and chronic whiplash headache are new diagnostic entities in the ICHD-2 (5.3, 5.4). In a prospective cohort study, 210 rear-end collision victims were identified consecutively from police records and asked about head and neck pain in questionnaires after 2 weeks, 3 months and 1 year. The results were compared with those of matched controls who were also followed for 1 year. Of 210 accident victims, 75 developed headache within 7 days. Of these, 37 had also neck pain and complied with the criteria for acute whiplash headache. These 37 had the same headache diagnoses, headache features, accompanying symptoms and long-term prognosis as the 38 without initial neck pain who therefore did not comply with the acute whiplash headache diagnosis. Previous headache was a major risk factor for headache both in the acute and chronic stage. Compared with the non-traumatized controls, headache in the whiplash group had the same prevalence, the same diagnoses and characteristic features, and the same prognosis. Both acute and chronic whiplash headache lack specificity compared with the headache in a control group, and have the same long-term prognosis, indicating that such headaches are primary headaches, probably elicited by the stress of the situation.

Prevalence of micro-emboli in symptomatic high grade carotid artery disease: a transcranial Doppler study.

BACKGROUND AND PURPOSE: Echolucent carotid plaques, as well as downstream micro-embolisation, may be associated with an increased risk of stroke. However, the relationship between carotid plaque ultrasound characteristics and micro-embolic signals (MES) detected in the middle cerebral artery (MCA) is still controversial. The purpose of this study was to investigate the prevalence of MES in patients with symptomatic high-grade internal carotid artery (ICA) stenosis and to identify predisposing factors, such as plaque echogenicity and intra stenotic blood flow velocity pattern. METHODS: 197 patients (mean age 69.5+/-8.6, 161 males) with confirmed symptomatic high-grade ICA stenosis and anti-platelet treatment underwent bilateral MES monitoring for 30 minutes within the anterior circulation, using Power M-mode transcranial Doppler techniques (TCD). Carotid artery plaques were characterized by Gray-Weale scaling. RESULTS: In 32.0% of the patients, we detected MES by TCD within the MCA on the symptomatic side, but the same finding was made in only 4.5% on the corresponding asymptomatic site (p<0.0001). The presence or absence of MES was associated with neither ultrasonic plaque characteristics nor the intrastenotic blood flow velocities at peak systole and end diastole. The median time since the last ischemic event symptoms was shorter in the patient group with MES [+] than in MES [-] (p=0.013). CONCLUSIONS: Despite optimum standard anti-platelet therapy, cerebral micro-embolisation occurs in 30% of patients with symptomatic carotid artery disease, which might therefore be a possible risk factor for recurrent neurological symptoms. However, the presence of MES is independent of intrastenotic blood flow disturbances and grey scale ultrasound plaque characteristics. The presence of MES as an indicator of unstable plaque and thereby a possible risk factor for stroke should be evaluated prospectively using various algorithms for plaque classifications.

Examination of the diagnostic validity of 'headache attributed to whiplash injury': a controlled, prospective study.

Acute and chronic headache attributed to whiplash injury are new diagnostic entities in the International Classification of Headache Disorders, second edition. A main objective of the present study was to assess the validity of these nosologic entities by studying the headache pattern in an inception cohort of 210 rear-end car collision victims and in 210 matched controls. Consecutive drivers involved in rear-end collisions were identified from the daily records of the Traffic Police Department of Kaunas, Lithuania. A standard self-report questionnaire was sent to the drivers between 2 and 7 days after the collision, and their passengers were recruited as well. Headache and neck pain were evaluated within 7 days of the collision, at 2 months and 1 year after the collision. A control group of non-traumatized subjects received questionnaires at the time of the selection and 1 year later. Of the 75 collision victims who developed headache within the first 7 days of the collision, 37 had a clinical picture in accordance with the criteria for acute whiplash headache (i.e., concomitant neck pain) and 38 did not. For acute headache after collision, concomitant neck pain was of no relevance to the headache type or its course. In both these subgroups, migraine and tension-type headache could be diagnosed in similar proportions and the prognosis after 2 months and 1 year was also similar. Preexisting headache was a strong prognostic factor in both groups for both acute and chronic pain. Compared with the non-traumatized control group, the 1-year incidence of new or worsened headache, or of headache improvement, was the same. A likely interpretation of the data is that acute headaches after rear-end car collisions mainly represent episodes of a primary headache precipitated by the stress of the situation. We conclude that the nosologic validity of both acute and chronic whiplash headache is poor as the headaches, in accordance with the criteria lack distinguishing clinical features and have the same prognosis compared with headaches in a control group.

A controlled prospective inception cohort study on the post-concussion syndrome outside the medicolegal context.

In an earlier historical cohort study on the post-concussion syndrome (PCS) in Lithuania, a country in which there are few confounding factors, the validity of this condition as a disease entity could not be confirmed. In order to register the post-traumatic symptoms, the influence of sociodemographic factors, and the effect of expectation on these symptoms more reliably, we performed a controlled prospective study. Three hundred subjects with concussion were followed up with repeated questionnaires for 1 year. For each study subject, a sex- and age-matched control person with minor non-head injury was identified. These controls received similar questionnaires. Headache both after 3 months and after 1 year did not differ significantly between the head-injured participants and the non-head-injured controls. Several other symptoms attributed to PCS did not differ significantly between the groups after 3 months. After 1 year the vast majority of symptoms did not differ significantly. Exceptions were slightly significant differences concerning memory problems, concentration problems, dizziness and tiredness. These differences were insignificant when analysing symptoms in unmarried and/or people with lower education, separately. No relationship between cognitive dysfunction and the severity of concussion was found. Although the possibility of a mild organic brain injury cannot be completely ruled out, our results cast doubt on the validity of PCS as a useful clinical entity, at least for head injuries with loss of consciousness for <15 min. Sociodemographic factors and expectation seem to influence reporting of symptoms after concussion.

Symptom expectation after minor head injury. A comparative study between Canada and Lithuania.

OBJECTIVES: The purpose of the present study is to compare the frequency and nature of expected symptoms in Lithuania (a country where the chronic post-concussive syndrome is largely unknown) with that in Canada. METHODS: A symptom checklist was administered to two subject groups selected from local companies in Kaunas, Lithuania, and Edmonton, Canada, respectively. Subjects were asked to imagine having suffered head trauma with loss of consciousness in a motor vehicle accident, and to check off symptoms they expected might arise from the injury. For symptoms they anticipated, they were asked to select the period of time they expected those symptoms to persist. RESULTS: In both the Lithuanian and Edmontonian groups, the pattern of symptoms anticipated closely resembled the acute symptoms commonly reported by accident victims with minor head injury. Yet, while many Edmontonians also anticipated symptoms to last months or years, very few Lithuanian subjects selected any symptoms as being likely to persist in a chronic manner. CONCLUSIONS: In Lithuania, despite the frequent experience of minor head injury in motor vehicle accidents, there is a very low rate of expectation of any chronic sequelae from such an injury, contrasting greatly with the response shown in Canada, where the prevalence of the chronic post-concussive syndrome is higher. Symptom expectation in some countries may be an important factor in the development of the chronic post-concussive syndrome.

Prevalence of temporomandibular disorders associated with whiplash injury in Lithuania.

OBJECTIVE: The purpose of this study was to ascertain the prevalence of symptoms of temporomandibular disorders in whiplash victims in Lithuania and compare it with the prevalence in otherwise healthy control subjects. STUDY DESIGN: In a controlled historical cohort study in Lithuania, we asked each of 210 victims of vehicular rear-end collisions (at 14-27 months after the accident) to report the presence and frequency of a number of temporomandibular disorder symptoms. The results were compared with those for an age-matched and gender-matched control group, sampled randomly from the local population. RESULTS: In the accident group, 2.4% of subjects (4/165) reported jaw pain for 1 day or more per month; this compared with 3.3% of the controls (6/180). One (0.6%) of the accident victims and 2 (1.1%) of the controls had daily jaw pain. In both groups there was a low prevalence of jaw sounds, pain in or near the ear(s), jaw locking, tinnitus, and facial pain. CONCLUSIONS: Unlike whiplash claimants in many Western societies, Lithuanian accident victims do not appear to report the chronic symptoms of temporomandibular disorders despite their acute whiplash injuries.

Pain after whiplash: a prospective controlled inception cohort study.

OBJECTIVES: In Lithuania, there is little awareness of the notion that chronic symptoms may result from rear end collisions via the so-called whiplash injury. After most such collisions no contact with the health service is established. An opportunity therefore exists to study post-traumatic pain without the confounding factors present in western societies. METHODS: In a prospective, controlled inception cohort study, 210 victims of a rear end collision were consecutively identified from the daily records of the Kaunas traffic police. Neck pain and headache were evaluated by mailed questionnaires shortly after the accident, after 2 months, and after 1 year. As controls, 210 sex and age matched subjects were randomly taken from the population register of the same geographical area and evaluated for the same symptoms immediately after their identification and after 1 year. RESULTS: Initial pain was reported by 47% of accident victims; 10% had neck pain alone, 18% had neck pain together with headache, and 19% had headache alone. The median duration of the initial neck pain was 3 days and maximal duration 17 days. The median duration of headache was 4.5 hours and the maximum duration was 20 days. After 1 year, there were no significant differences between the accident victims and the control group concerning frequency and intensity of these symptoms. CONCLUSIONS: In a country were there is no preconceived notion of chronic pain arising from rear end collisions, and thus no fear of long term disability, and usually no involvement of the therapeutic community, insurance companies, or litigation, symptoms after an acute whiplash injury are self limiting, brief, and do not seem to evolve to the so-called late whiplash syndrome.

Headache after whiplash: a historical cohort study outside the medico-legal context.

Headache is frequently reported as a chronic complaint after whiplash traumas. Criteria have been presented, but it has not been validated whether any specific headache type emerges after a trauma with whiplash mechanism. In a questionnaire-based historical cohort design, 202 adult Lithuanian individuals were interviewed 1-3 years after experiencing a rear-end car collision. The questionnaire was designed so that a diagnosis of migraine and tension-type headache in accordance with the International Headache Society criteria could be made. "Possible cervicogenic headache" was diagnosed according to Sjaastad et al.'s minimal criteria. The diagnostic panorama in those with traumas was compared with that of an age- and sex-matched control group. The introductory questions did not reveal differences in headache frequencies between the traumatized and control groups (p = 0.60). The prevalence of migraine and tension-type headache (both episodic and chronic) was also similar. A higher frequency of possible cervicogenic headache was observed in the traumatized group (10 vs 5), but the difference was not statistically significant (p = 0.28). Sixteen patients in the accident group had headache > 15 days per month, 11 of the 16 had similar complaints before the trauma, while 5 had worsened headache as compared to (the recollected headache) before the trauma. None of the patients with possible cervicogenic headache reported increased headache after the accident. Accordingly, the present results obtained outside the medico-legal context do not confirm that a specific headache pattern emerges 1-3 years after a rear-end car collision.

Natural evolution of late whiplash syndrome outside the medicolegal context.

BACKGROUND: In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions. METHODS: In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area. FINDINGS: Neck pain was reported by 71 (35% [95% CI 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8.4%; 5-13] vs 14 [6.9%; 4-12] and 19 [9.4%; 6-15] vs 12 [5.9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses. INTERPRETATION: Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.