Neck / Shoulder Tip Pains, Tired and Dizzy When Upright – Maybe Coat-hanger Hypotensive Events

Postural Hypotension (Low Blood Pressure on standing) is associated with neck and shoulder tip pains in what is thought a hypo-perfusion issue.  One should notice being dizzy standing up – something that can happen after head injury and also spinal cord injuries.

Spinal Cord. 2002 Feb;40(2):77-82.
The prevalence and association of neck (coat-hanger) pain and orthostatic (postural) hypotension in human spinal cord injury.
Cariga P, Ahmed S, Mathias CJ, Gardner BP.   abstract here

  • Neck /shoulder tip pains in 75% of subjects with Orthostatic Hypotension and 25% of subjects without (P<0.03) – 3 times the incidence
  • Might notice pain worse with  upright posture and exercise, and relief when lying down
  • Pains are called coat hanger because the involve neck and shoulder tips much like a coat hanger distribution
  • Dizziness on getting up could be a faintness combined with excessive tiredness

Cardiol J. 2010;17(5):482-7.
Autonomic dysfunction presenting as postural tachycardia syndrome following traumatic brain injury.
Kanjwal K, Karabin B, Kanjwal Y, Grubb BP.    abstract here

  • In brain injury cases, they talk about  a POTS (postural tachycardia syndrome) syndrome
  • caused by an autonomic dysfunction in which blood pools in legs on standing – might get muscle spasms at time and be called “diencephalic epilepsy”
  • dizziness, fatigue, palpitations and near syncope
  • 6/8 syncopal (fainting) episodes
  • 6/8 significant cognitive dysfunction
  • 3/8 chronic pain
  • In 5/8 there was a > 30 bpm from sitting to standing position and  in 3/8 there was an “absolute rise in heart rate > 120 bpm (n = 3) within ten minutes of assuming an upright posture.”
  • “All patients experienced a cold-like sensation followed by feelings of extreme fatigue, lightheadedness, palpitations and presyncope [near fainting] while upright which was relieved by recumbency [lying down]“
  • Condition confirmed by head-up tilt test (HUTT) – put on a board that is lying down at start then tilted to 70 ° upright for 30 minutes  – this should case symptoms and a rise in heart rate.  – “If no symptoms occurred, the patient was lowered to the supine position and an intravenous infusion of isoproterenol
    started, with a dose sufficient to raise the heart rate to 20–25% above the resting value. Upright tilt was then repeated for a period of 15 minutes.”

Treatments included: (all meds “off label”)
good review of POTS treatments here:
POTS Place: A Guide to Postural Orthostatic Tachycardia Syndrome

Includes many non drug treatments:

  • 8 glasses fluid/day
  • Raise head bed
  • Compression stockings
  • small frequent meals
  • lots of rest
  • exercise
  • increased salt intake
  • Posture measures:
    • standing with your legs crossed,
    • sitting in a low chair,
    • sitting in the knee to chest position,
    • leaning forward with your hands on your knees when sitting
    • tightening the buttocks, thigh and leg muscles when standing
  • Vitamins – Cerefolin mix suggested helpful

Drugs include:

Retain fluidFludrocortisone -starting at 0.1 to 0.2 mg /day or Desmopressin (DDAVP) acetate 0.1 to 0.2 mg orally at bedtime (have seen low sodium levels with latter)

Vasoconstrictor – Midodrine – 5 mg orally three to four times daily – added to above. Important to take their first dose of midodrine 15 to 20 minutes before getting out of bed.

Pyridostigmine – acetylcholinesterase inhibitor used to alter autonomic nervous system function – useful in post viral POTS or POTS associated with Sjogren’s or Lupus-  30-60 mg twice a day.

Stimulants – Methylphenidate (Ritalin) or Modafinil

Antidepressants – SSRIs are more helpful in neurocardiogenic (fast heart- low output) syncope, SNRI’s (duloxetine and  venlafaxine) for POTS – or better yet combined treatment.

Erythropoietin, a blood building hormone,  has vasoconstrictive properties and is used at 10 000 IU subcutaneously once weekly as long as hemotocrit stays under 50%.

Octreotide, a gut hormone, has vasoconstrictive properties -  used at 50 mg two
to three times daily.

If high adrenaline type POTS (fast heart) – clonidine  0.1 mg PO 3X day [patch in US]  or combined alpha and beta blocking drugs labetalol and carvedilol ( not a pure beta blocker)

Common mixes in post head injury include Cerefolin vitamin, SSRI antidepressant,  and Midodrine.

I wrote the author of head injury study and asked if treatment pf POTS helped the pain – he said a pain specialist was involved so no such conclusion could be reached.

Comment – I had one patient with syncopy secondary to Nardil MOA inhibitor therapy  – BP would drop so low he would get seizure-like activity. He has improved by decreasing dose.
POTS and chronic fatigue as interwoven. Now coat-hanger pain might as well. Should,  however,  notice relief lying down.

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