What is the best intervention for a patient who falls and complains of head pain and stiffness?

Management of Head Pain and Stiffness Following a Fall

For patients who fall and complain of head pain and stiffness, a prompt neuroimaging evaluation with CT scan or MRI is essential to rule out serious intracranial pathology, followed by appropriate pain management and assessment for underlying causes of the fall.

Initial Assessment and Triage

Immediate Evaluation for Serious Pathology

• Apply the Ottawa Subarachnoid Hemorrhage (SAH) Rule to determine risk of SAH 1:

  • Age ≥40 years
  • Neck pain or stiffness
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (instantly peaking pain)
  • Limited neck flexion on examination

• If ANY criteria are met, proceed with urgent neuroimaging:

  • Non-contrast head CT within 6 hours of symptom onset (sensitivity 98.7%, specificity 99.9%) 1
  • If CT is negative but high suspicion remains, or presentation is >6 hours after onset, lumbar puncture for xanthochromia evaluation is necessary 1

Assessment for Fall Risk Factors

• Evaluate using key screening questions 2:

  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Are you worried about falling?

• Perform Timed Up and Go (TUG) test (>12 seconds indicates increased fall risk) 2

• Assess for balance and mobility impairments, medication-related factors, sensory deficits, and cognitive impairment 2

Treatment Algorithm

If Serious Intracranial Pathology Suspected:

1. Stabilize and transfer to appropriate level of care
2. For suspected subarachnoid hemorrhage: urgent neurosurgical consultation 1
3. For suspected intracranial hypotension: consider MRI brain with contrast and MRI whole spine 1

If Serious Pathology Ruled Out:

1. Pain Management:

   • Acetaminophen for mild to moderate pain (first-line for safety) 3
   • NSAIDs if no contraindications
   • Avoid opioids for routine management 1

2. Physical Interventions:

   • Regular exercise with balance training 2
   • Physical therapy for neck pain and stiffness
   • Fall prevention education and counseling 1, 2

3. Environmental Modifications:

   • Home safety assessment
   • Remove tripping hazards
   • Install handrails and grab bars as needed 1, 2

Special Considerations

For Geriatric Patients

• Comprehensive multifactorial intervention program is recommended 2:

  • Medication review (especially psychotropic drugs)
  • Vision assessment
  • Treatment of cardiovascular disorders
  • Nutritional support

• Consider screening for osteopenia/osteoporosis 1

• Implement environmental safety measures in the home 1

For Patients with Neck Pain and Stiffness

• Evaluate for cervical spine injury or instability
• Consider cervical spine imaging if neurological symptoms present
• Physical therapy for neck mobility and pain management 4

Follow-up Recommendations

• Schedule follow-up within 1-2 weeks to reassess symptoms
• For geriatric patients, regular reassessment every 1-2 years for fall risk 2
• Consider referral to specialist care for patients with:
  • Persistent symptoms
  • Recurrent falls
  • Frailty or multiple comorbidities

Common Pitfalls to Avoid

• Failure to recognize the Ottawa SAH criteria when present 1
• Relying solely on CT scan when presentation is delayed >6 hours from symptom onset 1
• Providing advice about fall risk without implementing recommended changes 2
• Overlooking medication review as part of fall prevention strategy 1
• Missing cervical spine injuries in the presence of head pain 4

By following this structured approach, you can effectively manage patients who present with head pain and stiffness following a fall, minimizing morbidity and mortality while improving quality of life.