What could be causing my inability to hold my head up and intermittent left arm pain?

Urgent Neurological Emergency: Immediate Stroke Evaluation Required

You must immediately activate emergency medical services and obtain urgent brain imaging—this presentation of inability to hold the head up combined with left arm pain represents a high-probability acute stroke or critical neurovascular emergency requiring time-sensitive intervention. 1

Immediate Life-Threatening Considerations

The combination of these symptoms demands urgent evaluation for:

• Acute ischemic stroke affecting the posterior circulation (vertebrobasilar territory), which can present with neck muscle weakness (inability to hold head up) and unilateral arm symptoms 1
• Cerebral venous thrombosis (CVT), which can cause severe headache, neck pain, and focal neurological deficits including arm weakness—this is a life-threatening condition that can rapidly progress to hemorrhage and death 2
• Acute arterial occlusion of the subclavian or brachiocephalic vessels, causing arm ischemia and vertebrobasilar insufficiency from "steal syndrome" 2

Critical First Steps in Emergency Department

Perform these assessments immediately upon arrival:

• Check bilateral radial pulses and blood pressure in both arms—a difference >20 mmHg between arms confirms significant arterial compromise requiring immediate vascular surgery consultation 1
• Assess the "6 P's" of acute limb ischemia: Pain, Pallor, Pulselessness, Paresthesias (numbness), Poikilothermia (cool limb), Paralysis 1
• Perform Cincinnati Prehospital Stroke Scale: facial droop, arm drift, abnormal speech 1
• Examine for neck muscle weakness, particularly inability to maintain head position against gravity, which suggests brainstem or high cervical cord involvement 2

Mandatory Urgent Imaging

Brain MRI with diffusion-weighted imaging is the preferred initial test and must be performed immediately to detect acute ischemic changes, differentiate ischemic from hemorrhagic stroke, and identify cerebral venous thrombosis 1. If MRI is unavailable, perform CT head without contrast to rule out hemorrhage, but recognize this may miss early ischemic changes 1.

Additional imaging required:

• CT venography or MR venography to evaluate for cerebral venous thrombosis, which can present with these exact symptoms and requires anticoagulation despite hemorrhage risk 2
• Carotid and vertebral artery ultrasound to identify extracranial stenosis >70% requiring urgent revascularization 1
• CT angiography of neck vessels if arterial dissection or subclavian steal syndrome is suspected 2

Why This Cannot Wait

• Patients with unilateral numbness and weakness have a 10% risk of completed stroke within the first week, with highest risk in the first 48 hours 1
• The window for thrombolytic therapy in acute ischemic stroke is extremely limited—effective therapy requires treatment within hours of symptom onset 2
• Cerebral venous thrombosis can rapidly progress to life-threatening hemorrhage, seizures, and death if not diagnosed and treated emergently 2
• Acute arterial occlusion outcomes depend entirely on time to reperfusion—delayed treatment results in permanent disability or limb loss 1

Common Pitfall to Avoid

Do not attribute these symptoms to musculoskeletal neck pain or rotator cuff tendinopathy 2. While rotator cuff problems are common and can cause arm pain, they do not cause inability to hold the head up. The combination of neck muscle weakness with arm symptoms is a red flag for central nervous system pathology, not peripheral musculoskeletal disease.

Do not consider intracranial hypotension as the primary diagnosis 2, 3. While intracranial hypotension can cause severe headache and neck pain, the key distinguishing feature is orthostatic headache (worse when upright, better when lying down), and it does not typically cause inability to hold the head up or focal arm symptoms 3.

Treatment Algorithm Based on Diagnosis

If acute ischemic stroke confirmed:

• Dual antiplatelet therapy (aspirin + clopidogrel 75 mg) for first 21 days, then long-term single antiplatelet therapy 1
• Immediate vascular surgery consultation for thrombectomy if large vessel occlusion identified 1

If cerebral venous thrombosis confirmed:

• Intravenous heparin should be initiated and continued even if hemorrhage develops, per American Heart Association/American Stroke Association guidelines 2
• Hypertonic saline and mannitol for elevated intracranial pressure management 2

If subclavian steal syndrome confirmed:

• Endovascular revascularization for symptomatic vertebral artery stenosis ≥50% with recurrent ischemic events despite optimal medical management 2