5.2.2 Persistent headache attributed to mild traumatic injury to the head

Identification: 32-year-old right-handed male, rideshare driver.

History of Present Illness: 8 months ago, the patient was involved in a traffic accident (frontal collision) without loss of consciousness, but with significant head impact on the steering wheel and cervical torsion. Since then, he reports daily headaches, described as a heaviness, located in the occipital region, radiating to the bilateral frontal and temporal regions. The pain is described as moderate to severe (7/10 on the visual analog scale), worsening with cervical movements, physical exertion, and stress. He also reports cervical stiffness and occasional dizziness. There is no significant improvement with common analgesics (paracetamol and ibuprofen).

Personal History: Well-controlled arterial hypertension. No previous history of chronic headache.

Physical Examination: Neurological: No motor, sensory, or reflex deficits. Pupils are isocoric and reactive to light. Cervical: Limited range of motion (especially rotation and extension), tenderness on palpation of the cervical paravertebral muscles, and trigger points in the suboccipital region. Other: No signs of infection or systemic changes.

Complementary Exams: Cranial CT (post-accident): No acute lesions (hematomas, fractures, or edema). Cranial and cervical spine MRI: Mild disc protrusion at C5-C6 without significant radicular compression. Transcranial Doppler: No vascular alterations.