What is the recommended treatment for whiplash?

Treatment for Whiplash

Begin immediate treatment with scheduled acetaminophen 1000 mg every 6 hours combined with topical NSAIDs (such as diclofenac gel with menthol) applied directly to the neck, while strictly avoiding opioids and limiting cervical collar use to a maximum of 2-3 weeks. 1, 2

Immediate Pharmacological Management

First-Line Therapy

• Administer acetaminophen 1000 mg orally or intravenously every 6 hours on a scheduled basis (not as-needed), as this provides superior pain control compared to PRN dosing and represents the cornerstone of acute whiplash management 1, 2
• Apply topical NSAIDs (diclofenac gel with or without menthol) directly to the painful neck area as first-line therapy, which has the greatest benefit-harm ratio for musculoskeletal injuries including whiplash 1, 2
• Ensure total daily acetaminophen does not exceed 4000 mg from all sources to avoid hepatotoxicity 2

Second-Line Pharmacological Options

• Consider adding oral NSAIDs (ibuprofen or naproxen) only if pain remains severe despite acetaminophen and topical NSAIDs, though use cautiously in patients with cardiovascular disease, hypertension, renal insufficiency, heart failure, or peptic ulcer disease risk 1
• Co-prescribe a proton pump inhibitor if oral NSAIDs are used, particularly in elderly patients or those on ACE inhibitors, diuretics, or antiplatelets 1

Medications to Avoid

• Strictly avoid opioids (including tramadol) as they provide no superior benefit compared to NSAIDs for whiplash and muscle strains, while significantly increasing risks of respiratory depression, over-sedation, nausea, dizziness, and progression to long-term opioid use 1, 2
• The evidence is clear: for musculoskeletal injuries like whiplash, no opioid provides better benefit than NSAIDs, and opioids cause the most harms 1

Non-Pharmacological Interventions

Physical Modalities

• Apply ice packs to the neck during the first 24-48 hours, followed by heat applications thereafter to reduce swelling and alleviate pain 1, 2, 3
• Implement transcutaneous electrical nerve stimulation (TENS) if available, which can reduce pain by approximately 2 cm on a 10-cm visual analog scale 1, 2
• Consider acupressure techniques if available and accessible, which demonstrated pain reduction of 1.59 cm on visual analog scale 1, 2

Activity and Mobilization

• Advise the patient to remain active rather than immobilized, as early active mobilization promotes better outcomes than passive treatment 1, 2, 4, 5
• Limit cervical collar use to a maximum of 2-3 weeks, as prolonged immobilization delays recovery and should be avoided 2, 3, 6
• Encourage range of motion exercises within pain limits, as early passive mobilization and exercises may accelerate recovery 3, 5

Imaging Considerations

• Recognize that whiplash diagnosis relies primarily on clinical factors, not imaging findings, as most whiplash patients have negative imaging despite real pathology 2
• Obtain cervical spine CT or radiographs only if you suspect fracture, dislocation, or the patient has high-risk features (not for routine whiplash) 2
• MRI cervical spine without contrast is the reference standard if soft tissue injury is suspected, though it tends to overestimate injury severity with false-positive rates of 25-40% 2

Prognosis and Follow-Up

• Most patients recover within 3 months, but persistent neck pain occurs in more than 30% at 2 years, and headaches persist in more than 10% 3
• Risk factors for poor recovery include: older age, interscapular or upper back pain, occipital headache, multiple symptoms, paresthesias, reduced cervical range of motion, objective neurologic deficits, and pre-existing degenerative changes 3
• For patients with minimal functional impairment (Quebec Task Force Grade I), the therapy recommendation "act as usual" with adapted pain treatment using NSAIDs is sufficient, with chronification rates as low as 3.1% 5

Critical Pitfalls to Avoid

• Never prescribe opioids for acute whiplash, as they increase risk of prolonged opioid use (ranging from <1% to 13% transition to long-term use) without superior pain relief compared to non-opioid alternatives 1, 2
• Do not exceed 4000 mg total daily acetaminophen from all sources, particularly if combining with other acetaminophen-containing products 2
• Avoid prolonged cervical collar immobilization beyond 2-3 weeks, as this delays recovery 2, 3
• Do not assume normal imaging excludes significant injury, as whiplash-associated disorders rarely show specific imaging findings despite real soft tissue pathology 2, 3