Purpose: This case outlines the complexity of differential diagnosis and management of headache-related symptoms when multiple diagnoses are present, implication for patient well-being, and the need for improved healthcare provider preparation. Case Presentation: A 16-year-old female equestrian athlete, competitive in eventing, presented with headaches, dizziness, and syncope events, with no history of head or neck trauma. Upon initial evaluation, cardiovascular screen and head CT were insignificant. During subsequent evaluation by another provider nearly 3 years later, the patient presented with advanced symptoms. Management and Outcomes: Initial management included prescription of oral contraceptives, methocarbamol, and ibuprofen PRN, which provided partial relief of symptom intensity but not frequency. Oral contraceptives were changed after 1 year, without improvement of symptoms. The patient's symptoms progressively worsened, ultimately impairing activities of daily living and limiting her riding time. Almost 3 years after the initial evaluation, the patient was referred to a neurologist, where a cervical MRI revealed a small syrinx and straightening of the cervical lordosis, and EMG testing showed bilateral shoulder rigidity, indicating severe cervical lordosis. Two months later, a full spinal MRI showed syringomyelia from C4-T12. The patient was referred to physical therapy to improve cervical strength and range of motion (ROM). Manual therapy sessions, massage therapy, and chiropractic care later complemented physical therapy. Following the addition of manual therapy techniques, the patient reported improvement in ROM and reduced frequency of headaches and dizziness. Conclusions: Equestrian athletes may be predisposed to higher stress on the cervical musculature, given the nature of the sport and the complex biomechanics of stabilizing the head and neck while on a moving base of support. Healthcare providers treating this population may not be familiar with the nuances of the sport. In this case, an equestrian athlete presented with a complex combination of symptoms for which initial treatment strategies were unsuccessful. Accurate diagnosis was delayed 3 years from initial evaluation, resulting in worsening symptoms and development of new symptoms. This case reflects the significant misdiagnosis and symptom dismissal rates in the broader literature, illustrating the need for better patient care and provider education.
