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.

This entry was posted in chronic fatigue, myofascial pain, Neck. Bookmark the permalink.

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

  1. Nicole Wharff says:

    I Have This. I’ve Been Trying To Explain This To PC For 3Years. I Somehow Managed To Pass The Tilt Table Test. They Also Have Taken My BP In All Positions. My SymptomsHave Come And Gone For Months In End. Get Worse Each Day . IHave Ended Up In The Hospital Twic I Have Two Additional Symptoms To Add: My Eyes Can Not Focus And I Seem To Have An Increase In Urine Output. On My Own I Have Started Taking Salt Tablets. Usually Only One A Da Depending ON Symptoms. I Stopped This Treatment For Six Weeks FearfulAnd Symptoms Returned Full Force. My Questions To You Are: 1 How Long Does Salt Stay In You System And What Do I Tell My PC. What Other Test Need To Be Performed? Could I Of Possibly HadEnough Salt.In My System To Be Able To Pass The Tilt Test? My PC Isn’t Aware Of My Salt Increase And The Amazing Turn Around He Sent Me Out Of His Office With SomeAtivan And Told Me It Was Anxiety .It’s Not ,It’s This.What Can I Do Next? Oh I Have HypothyroidIsm And No Brain Trama. Just A Spinal Fusion 13 Years Ago. These Symptoms Showed Up AFter The Birth Of My Son Thank You

    High salt consumption is associated with increased blood pressure and would need monitoring – both upright and if there is postural hypotension – lying down. I have a case that has achieved normal sitting blood pressure but significantly elevated bp lying down. There are other meds that work for positional hypotension – my favorite is sertraline – which your doctor would easily prescribe because they also use if for anxiety/depression. It has few side effects at lower doses and works in some cases:

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