The topic we will discuss in this case is headaches.
The Plaintiff suffered from persistent and debilitating headaches. Headaches are a common symptom that may result post motor vehicle collision. There are different types of headaches however and various types of treatment that may or may not assist with headaches. This case is educational and explores the differentiation between whiplash-type headaches vs. tension-type headaches and management of the treatment plan. We will also learn more about the Montreal Cognitive Assessment (MoCA) tool and considerations of when this screening tool may not be helpful. We will review the topic of medication overuse as a potential cause for ongoing headaches.
We will look at the differing views of the neurologists specifically dealing with headaches. Rather than paraphrasing, I will also quote directly from this case as it is important to understand the analysis and approach in this case.
We will identify the symptoms reported by the Plaintiff, but first I want to highlight that there were two collisions involved. Liability was not an issue. The key resulting symptom from these 2 collisions was debilitating and persistent headaches which resulted after the 1st collision.
The primary focus is to assess the impact of the ongoing headaches on the Plaintiff’s daily life of work, home life and social life.
The referenced case is noted: Puri v. Vuong, 2020 BCSC 28 (CanLII).
This case was well presented by both sides. Damages were awarded in the sum of $278,224. This result clearly shows how headaches can have a significant impact on one’s life and should not be left untreated.
It is also worth noting that these collisions were not minor. The first collision rendered both the Plaintiff’s vehicle and the Defendant’s vehicle a write off, with over $14,000 damage to the Plaintiff’s vehicle, quite a substantial crash.
Here is the breakdown of the awarded damages:
Past loss of income $52,820.
Loss of future earning capacity $120,000.
Cost of future care $6,945.
Special damages $8,459.
• neck pain
• pain in his shoulders,
• pain in the low back and wrists
• bruise on his right arm
• nausea with headaches
The Plaintiff also was off work for 6 weeks after the first collision.
• headaches never go away
• severe headache also comes with nausea
• requires breaks when working on a computer
• standing for long periods increases pain in shoulder and neck
• this pain also triggers headaches
• with acute headaches, focus is difficult
• diminished concentration
• difficulty remembering names and is preoccupied with pain
• is not able to communicate with his children
• impacts his leisure activity of cricket
• resulting emotional impact from ongoing pain
• lacks confidence and worries about his future
As we will see in this case, the treatment that one goes through is very important and was a lengthy discussion in this case. This is a good example of how important it is to pay close attention to the specific treatment plan of the Plaintiff in existing claims, which includes the type of medication taken post collision.
• Massage therapy
• Pain medications (pay close attention to this category)
• Injections of a local anaesthetic in neck and shoulders
• Botox injections
Unfortunately, none of the treatment sought by the Plaintiff assisted with his ongoing pain in any meaningful way. He did have the most relief with “active physiotherapy” which involved active movement, rather than simply using electrodes.
In relation to the headaches, we will take a closer look at the reported symptoms noted in the clinical records of the Plaintiff’s GP:
• Constant headaches reported at 4/10 occurring 20 days a month;
• Headaches interfere with his life “to a moderate extent.”
• Headaches impact activity levels of his occupation due to reduced tolerance
• Headaches increase with standing and walking
• Further treatments or rehabilitation was unlikely to improve his situation
• Recommended life-long access to a gym and exercise equipment in the home
Let’s begin with the defence neurologist, Dr. Manu Mehdiratta, who offered detail with respect to the type of headaches and focused on the Plaintiff’s treatment plan which was “not managed” properly according to Dr. Mehdiratta. I will also note that Dr. Mehdiratta was cross-examined vigorously and at length and his opinion was not undermined. The Court accepted the testimony of Dr. Mehdiratta and we are going to go over the evidence and the cross-examination of this expert:
Dr. Manu Mehdiratta
• Examination was unremarkable
• Reduced range of motion in the cervical and lumbar spines
• Neurological diagnosis was tension-type headaches and migraines
• Opinion focused on medication overuse
• Opinion was that there was “no permanent disabilities from a neurological perspective.”
• Plaintiff has not received appropriate and effective treatment for tension-type headaches
• Recommends decreased use of Vimovo and Tylenol
• Suggestion of a trial use of Elavil
• Doubtful there was any cognitive impairment
• Headaches may affect attention (frontal lobe / attending to tasks);
• Administered MOCA test which suggested mild cognitive impairment – but MOCA is not helpful
• Problems due to reduced attention rather than reduced cognition
Dr. Mehdiratta states the following as it pertains to tension-type headaches:
 In his examination in chief, Dr. Mehdiratta explained that a “tension-type headache” is a headache commonly associated with neck strain or whiplash-type injuries. He said they are still “important”, but need proper treatment.’
 As to his comment about medication overuse, Dr. Mehdiratta said medications such as those taken by Mr. Puri are like “candy for the brain” in that the brain will tend to want more “candy”. He said there is a need to stop the “rebound” effect of coming off the medication or the headaches will not stop.
What is MOCA ?
The Montreal Cognitive Assessment (MoCA) is a widely used screening assessment for detecting cognitive impairment. It was created in 1996 by Ziad Nasreddine in Montreal, Quebec. It was validated in the setting of mild cognitive impairment, and has subsequently been adopted in numerous other settings clinically. Wikipedia
Also note MoCA is a:
“straightforward tool for diagnosing patients and gauging an appropriate follow-up and treatment plan. With the ability to assess several cognitive domains, the MoCA test is a proven and useful cognitive screening tool for many illnesses” www.mocatest.org
When is MoCA not helpful – Considerations outlined by Dr. Mehdiratta:
(1) this MOCA score was not consistent with the MOCA score reported by one of Mr. Puri’s physicians, which was normal;
(2) the MOCA is not suitable for people whose first language is not English, and Mr. Puri’s English was not good enough;
(3) the MOCA is focused more on head injury or concussion cases and so is not really appropriate here;
(4) the MOCA is a screening tool, not a diagnostic tool; and
(5) the MOCA does not distinguish between cognitive problems, on the one hand, and attention problems caused by headaches, on the other.
 Dr. Mehdiratta felt that the role of medication overuse had not been adequately addressed in Mr. Puri’s case. He agreed that if the headache is associated with a cause (that is, whiplash) it is correctly described as being secondary to that cause, but he said if the headache continues, then medication overuse must be considered as a potential primary cause for the continuation of symptoms. A whiplash-associated headache would tend to resolve, and if it does not then one has to consider why the headache persists. He also noted that Mr. Puri’s headache was not aggravated by routine physical activity, which also suggests it is not related to a whiplash-type injury.
 Dr. Mehdiratta was not in favour of ongoing physiotherapy and massage therapy. He said if Mr. Puri’s treatment focused on better medication management, then those modalities will not be needed. Even if the headache is in fact whiplash-based then these therapies would only be useful for a limited period of time.
I will also quote directly from this decision on the differing views of both neurologists and the points raised in cross-examination as this relates to the argument of the diagnosis and prognosis of the headaches:
Opinions of the Neurologists
 Both of the neurologists who gave evidence accept that the plaintiff has ongoing headaches, but they differ somewhat on the diagnosis. Dr. Chahal, the plaintiff’s expert, diagnosed “Persistent Headache attributed to a whiplash injury” and opined that Mr. Puri’s headaches are likely to persist for the foreseeable future. While Dr. Chahal acknowledged that headaches associated with whiplash can resolve once the whiplash symptoms themselves resolve, he said sometimes this does not happen.
 Dr. Mehdiratta, the defence neurologist, diagnosed a “tension-type headache and migraine”, along with medication overuse. He said a “tension-type headache” is a headache commonly associated with neck strain or whiplash-type injuries. He was of the view that Mr. Puri had not yet received appropriate and effective treatment for tension-type headaches, and he made some recommendations for a trial of different medications. He was also concerned about medication overuse and felt that this potential cause had not been adequately explored. He noted, in particular, that a whiplash-associated headache would tend to resolve, and if it does not then one has to consider why the headache persists. He also noted that Mr. Puri’s headache is not aggravated by routine physical activity, which he said also suggests it is not related to a whiplash-type injury.
 Plaintiff’s counsel cross-examined Dr. Mehdiratta vigorously and at length and, in submissions, counsel was highly critical of Dr. Mehdiratta. I do not agree with those criticisms.
 I will not review every point and counterpoint from the cross-examination, but will address a few key elements. Counsel cross-examined Dr. Mehdiratta on a reference work, The International Classification of Headache Disorders, 3rd Edition [ICHD], which Dr. Mehdiratta acknowledged was an authoritative reference work. There was an extended debate between counsel and witness over specific entries and wording in the ICHD. Ultimately, counsel submitted that Dr. Mehdiratta had not shown Mr. Puri’s situation fits in with the ICHD checklist of the “medication overuse” type of headache. Dr. Mehdiratta responded with words to this effect (from my notes):
But we don’t normally do a checklist like this. If we did, you wouldn’t need a neurologist. The ICHD is the science, clinical judgment is the art.
 I accept Dr. Mehdiratta’s testimony that there is more to a diagnosis or potential diagnosis than merely following a checklist, and that clinical judgment plays an important role. I did not find Dr. Mehdiratta’s opinion to be undermined to any extent on this point.”
 A second criticism of Dr. Mehdiratta was aimed at his recommendation that Mr. Puri’s pain medications be reduced together with a trial of Elavil (amitriptyline). The criticism was based on the fact that amitriptyline had been trialled before. Dr. Mehdiratta acknowledged that he had not seen a reference to that earlier medication trial, but he noted that the dosage involved in that trial would have been too low (10 mg., versus his recommended dose of 50 mg.), and the duration too short given that only a 10-day supply was prescribed and “a decent trial would be three months”. Given that explanation, this aspect of cross-examination did not undermine Dr. Mehdiratta’s opinion.
 Finally, plaintiff’s counsel was critical of Dr. Mehdiratta for not reviewing a Pharmanet printout to ascertain exactly how much medication Mr. Puri was taking. In response, Dr. Mehdiratta pointed out that most of the medication Mr. Puri was taking consisted of over-the-counter medication, which does not show up on a Pharmanet printout. I note that in his report Dr. Mehdiratta set out the medications, and the amounts of medications, Mr. Puri said he was taking, something Dr. Mehdiratta could rightly rely upon. Parenthetically, I note that Mr. Puri testified at trial to taking more medication than he apparently told Dr. Mehdiratta. In any event, there was a factual basis on which Dr. Mehdiratta could properly base his opinion.
 In brief, I found that Dr. Mehdiratta’s opinion emerged unscathed after counsel’s lengthy and vigorous cross-examination. I found Dr. Mehdiratta to be careful and thorough. I also had the impression that he delved deeper into Mr. Puri’s headache problems than did Dr. Chahal.
 To conclude on the expert neurological evidence, Dr. Chahal and Dr. Mehdiratta essentially agree that Mr. Puri’s headaches, to a certain point in time at least, are related to his whiplash-type injuries. Dr. Chahal believes they still are, and says Mr. Puri’s headaches are likely to persist for the foreseeable future. Dr. Mehdiratta believes Mr. Puri has not yet received appropriate and effective treatment for tension-type headaches and that medication overuse, as a cause of the ongoing headaches, had not been adequately explored.
 In my view, neither neurologist is obviously wrong or obviously right. I accept both of their opinions, at least to some extent. The difference between the two opinions seems to be one of treatability. Based on all of the evidence, and in particular the neurological opinions, I conclude that Mr. Puri’s headaches will likely continue for some time, though they seem to be moderating at least somewhat, and there is a prospect that other treatments will further ameliorate his symptoms.
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