Headaches can be tricky to diagnose and treat. In the headache section of the neck pain CPG, the authors recommend consulting two additional resources: the IHS's International Classification of Headache Disorders and the NICE's Headaches in Over 12s document. In this episode, David pulls the most important information from those documents together to help you distinguish some of the most common types of headaches.
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Hello everyone and thanks for joining us again. I hope everyone has had a peaceful holiday season and has a happy new year. As we have just finished talking about the neck pain CPG, and as we are preparing to wrap up a year that—for many—will live in infamy, it seemed fitting for our last episode this year to cover headaches. Headaches are a pain to have, and often a pain to treat. There’s a lot about headaches that we don’t fully understand. The International Headache Society has attempted to classify all the various types of headaches in their publication called, “The International Classification of Headache Disorders.” The latest, 3rd edition of of this document, published in 2018, lists 14 broad classifications of headaches, each with 2-13 subclassifications, then even more sub-subclassifications, and a few sub-sub-subclassifications for good measure. Of course, you aren’t expected to know all the headaches listed in this 211-page document for the OCS exam. For example, one category is “Headache attributed to a substance or its withdrawal.” This is not something we are typically going to diagnose as physical therapists. Another type of headache is, “Headache attributed to ingestion or inhalation of a cold stimulus.” A portion of the description reads, “Rapid ingestion of crushed ice slurry is particularly likely to provoke this headache, but eating ice-cream even slowly can do so.” So if you’ve ever wanted to know where to find the clinical classification for a brain freeze, OCS Field Guide Podcast is here to help you out.
So you definitely don’t need to know every possible kind of headache for the exam, but I’m going to cover a few that I think you might encounter: cervicogenic headache, tension-type headache, migraine, and cluster headache. Let me emphasize: there are other types of headaches, and there can be overlap between types of headaches. If you want to dive really deep, you can find a link to the IHS’s International Classification of Headache Disorders on the resources tab of our website. But my personal opinion is that these four are the big ones you should recognize.
First, cervicogenic headache. In the neck pain CPG that Austin just covered, this is called, “neck pain with headaches.” But the most common name, and the one that the International Headache Society uses, is “cervicogenic headache.” The IHS defines cervicogenic headache as, “Headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.”
Specifically, a cervicogenic headache is going to come from a dysfunction of the upper cervical spine. It’s crucially important for your differential diagnosis to recognize that C1-3 and trigmenial afferent nerves, which includes branches like the auriculotemporal nerve, all converge at the same trigeminocervical nucleus. So C1-3, the trigeminal nerve, and the auriculotemporal nerve, which innervates the external portion of the tympanic membrane as well as the posterior TMJ, all converge at the same nucleus. So afferent signals coming from any of these nerves might be interpreted by the brain as coming from one of the others that converge at this nucleus. For this reason, upper cervical dysfunction can sometimes present as TMJ pain or a sensation of fullness in the ear. And TMJ dysfunction can sometimes present as a headache or can be accompanied by tinnitus. Or, yes, a mobility impairment at C1 and C2 can be felt as a headache.
I also want you to notice that we’re not talking about myofascial trigger points here. There are sometimes cervicogenic headaches that also present with trigger points, and some people can have overlapping headache causes. But a cervicogenic headache, by definition, comes from dysfunction of the cervical spine. Headaches from trigger points fit better in a couple other categories, which we will talk about shortly.
So how do we diagnose a cervicogenic headache? Cervicogenic headaches are usually unilateral, and they are aggravated with neck movements or sustained postures. Positive findings include positive cervical flexion-rotation test, reproduction of headache with spring testing, limited cervical ROM, restricted upper cervical segmental mobility, and strength or endurance or coordination deficits of the neck muscles. So a right sided headache that is worse when looking to the right or worse with prolonged postures should make you suspect cervicogenic headache. A positive right cervical flexion-rotation test, which is intended to isolate C1/C2 segmental mobility, would confirm this suspicion. And if, in addition to these other signs, the headache is reproduced with C1/2 spring testing, this should be a no brainer.
You may recall the treatments for cervicogenic headache that Austin covered in the last episode. To drive them home, I’ll mention them again. Since the issue with cervicogenic headaches appears to be C1/C2 mobility, you’ll notice that the recommended treatments are focused on restoring that mobility. In the acute phase, there is a B-level recommendation for supervised instruction in active mobility exercise and a C-level recommendation for the C1-2 self-SNAG exercise. In the subacute phase, we have a B-level recommendation for cervical manipulation and mobilization, and another C-level recommendation for the self-SNAG exercise. For chronic cervicogenic headaches, the CPG gives a B-level recommendation to cervical or cervicothoracic manipulation or mobilizations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.
Let’s move on to tension-type headaches. Tension-type headaches have previously been called stress headaches, muscle contraction headaches, or psychomyogenic headaches. They have a lifetime prevalence of 30-78% in the general population, so they’re fairly common. The pathophysiology of tension-type headaches is not well known, but, to quote the International Headache Society, “increased pericranial tenderness is the most significant abnormal finding in patients with tension-type headaches.” These individuals have facial and cervical muscles that increase in tenderness to palpation during a headache episode but can also remain tender to a lesser degree in between episodes. (If, in the back of your head, you’re thinking about myofascial trigger points, you’re probably onto something.) Tension-type headaches are typically episodic, and they can progress from infrequent to frequent to chronic. The IHS description of episodic tension-type headache reads that the headache is “typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, although photophobia or phonophobia may be present.” In order for the diagnosis to be made, the individual has to have had at least 10 episodes.
So let’s recap to make sure you get that: tension-type headaches are associated with tenderness in the face and neck that is worse during the episodes and worse with palpation. The headache can last from minutes to days and is usually described as a bilateral pressing or tightening of mild to moderate intensity. Sensitivity to light or sound can be present—but only one, not both. Nausea is not typically present, and the headache is not worsened by physical activity.
So what do we do with tension-type headaches? I’m going to start pulling some information from a guideline published by the National Institute for Health and Care Excellence in the UK that our neck pain CPG says we should consult for non-cervicogenic headaches. (I’ll post a link to it on our website.) This document recommends medical management with aspirin, acetaminophen, or NSAIDs for acute treatment, and acupuncture for prophylaxis. In our own literature, there is some evidence for manual therapy including soft tissue mobilization for tension-type headaches. And if those tender spots that are associated with tension-type headaches left you itching to do some dry needling, you have good instincts! There is growing evidence for dry needling in this population. A somewhat large randomized controlled trial by Gildir et al in 2019 showed significant findings with large effect sizes favoring trigger point dry needling when compared to sham needling in this population.
Because tension-type headaches are episodic and recurrent, they are sometimes confused with migraines. So let’s talk about migraines next. Migraines are very common and are a leading cause of disability. Migraines can either occur with an aura or without an aura. Both types can involve prodromal symptoms that start hours or a couple days before the onset of the migraine and “warn” the individual that the migraine is coming. Prodromal symptoms can include fatigue, difficulty concentrating, neck stiffness, sensitivity to light and sound, nausea, blurred vision, yawning, and pallor.
Migraines have traditionally been connected to decreases in blood flow to different areas of the brain, but in migraines without auras, there is conflicting evidence about the extent to which this happens. There is some increasing support for the idea that these migraine attacks that lack auras may originate in the central nervous system and, among other things, involve sensitization of pain pathways. The IHS describes a migraine without aura as, “Recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.” I’ll point out the key features again: unilateral location, pulsating quality, moderate or severe pain intensity, aggravated by routine physical activity (like walking or climbing stairs), and nausea and/or photophobia and photophonia.
The IHS describes a migraine with aura as, “Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.” So migraines with auras are characterized by a fully reversible central nervous system symptom that comes on gradually prior to the migraine. The migraine itself follows the same pattern as a migraine without an aura.
Migraines with auras are clearly connected to decreases in blood flow in the brain and sometimes in the brain stem. So these auras can present as visual symptoms, sensory symptoms, speech or language disturbances, or motor weakness. And if the source of the migraine is the brain stem, the aura can present as dysarthria, vertigo, tinnitus, diplopia, or ataxia. But this is less common. The most typical auras are visual disturbances, followed by sensory disturbances.
Some of these auras can be alarming to those of us taught to watch our for our Ds and Ns. But one of the distinguishing features of migraines is that they are recurrent. And each migraine might present with slightly different symptoms, but generally those who get migraines have typical clusters of symptoms that they are used to seeing. For this reason, it’s necessary for an individual to have five episodes before a diagnosis is made. So if an individual presents to your clinic with some strange neuro signs, like paresthesias, but they have a clear history of migraines with an aura that presents as paresthesias, and their report and their history confirms that this is typical for them, then you don’t necessarily need to panic.
To summarize, migraines with auras are typically unilateral, start with an aura (which is typically visual), and last 4-72 hours. The aura makes these easy to identify in a patient case. It’s harder to identify migraines without auras. In migraines without auras, the feature that distinguishes them from tension-type headaches and cervicogenic headaches is aggravation with routine physical activities like climbing stairs. This does not typically aggravate tension-type headaches or cervicogenic headaches. And if the headache is also associated with nausea, that can help point you toward migraine without aura as well, since tension-type headaches and cervicogenic headaches are not typically associated with nausea.
Now how do we treat migraines? There isn’t nearly as much clear clinical evidence for PT in the treatment of migraines as there is for something like cervicogenic headaches. That doesn’t mean PT can’t help at all, but it means we don’t have an overwhelming amount of evidence for the OCS exam item writers to test you on. There is some evidence for manual therapy to make marginal improvements in pain and disability in individuals with migraines, but if you think about the proposed theoretical mechanisms of migraines—decreased cortical or brain stem blood flow or central nervous system attacks—PT would mostly be modulating symptoms rather than addressing the underlying causes. So for the most part, we need to know how to distinguish these patients from cervicogenic and tension-type headaches so we can better adjust our prognosis and expectations for intervention, and so we can consider referral to a neurologist or pain management physician who specializes in migraines.
That might be more about migraines than you ever wanted to know, but trust me, that’s really just the tip of the iceberg. But I think that is plenty for the purposes of the OCS exam. Let’s move on to cluster headaches.
Cluster headaches are severe to very severe headaches that occur in groups—or clusters. The IHS defines them as, “Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to eight times a day. The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.” Cluster headache attacks can last for weeks or months and are separated by remission periods lasting months or years. The pain is excruciating, and patients are typically unable to lie down. Instead, they tend to present with restlessness and pace the floor. Age of onset is typically 20-40, and men are afflicted three times more often than women.
So, to reiterate, cluster headaches occur in clusters. The individual headaches last 15 minutes to three hours, and they are characterized by severe, unilateral pain behind the eye, above the eye, or in the temporal region. The headache is accompanied by restlessness and/or nervous system signs on the ipsilateral side of the face, including conjunctival injection, production of tears, nasal congestion or runny nose, eyelid edema, forehead or facial sweating, and pupillary restriction or drooping eyelid.
So how do we treat it? Again, this is a situation where we have limited evidence for PT treatment, so we need to be sure we’re communicating and referring to an appropriate provider when necessary. The NICE guidelines from the UK that I mentioned before recommend oxygen and nasal triptan for these headaches—which, of course, we don’t prescribe, but we can get these people to someone who does.
As I said at the beginning of this episode, these are not the only headaches out there, and they are not the only ones you will encounter. But I think these are the most common headaches you might have to differentiate between on the exam. Let’s tie all this information together by clinical feature.
If you like visual representations of information like this, I’m going to be putting together a chart for our Patreon page. You can find a link in the episode details and become a supporter to get access to it.
Now let’s practice a little.
A 33-year-old male presents for an evaluation with a chief complaint of R-sided headache that radiates from above his R eye in a ram’s horn pattern. He notices it get worse when he is working at his desk, and the pain continues for as long as he remains working. After work, he lies down with a heating pad on his neck and face to relieve the headache. He denies sensitivity to light or sound and denies nausea. What objective measure will be most useful in confirming this patient’s suspected diagnosis?
A. Palpation of facial and cervical muscles for tenderness
B. Cervical flexion-rotation test
C. Visual field screening
D. Cervical distraction test
To answer this, you need to know two things: the most likely diagnosis, and what test will be most useful in confirming that diagnosis. You don’t have as much information as you might like here, but you have enough to form a likely hypothesis. The pain is unilateral, which rules out tension-type headache. He does not have nausea, photophobia, or phonophobia, which rules out migraine. He lies down to get relief, which rules out cluster headache. This R-sided headache provoked by prolonged positioning looks cervicogenic, and so the cervical flexion-rotation test is the best answer.
Let’s try another.
A 26-year-old female patient presents with a L-sided headache and nausea. She reports that the headache started gradually 2 days ago, and she describes the pain as severe. She says that climbing the stairs makes the pain worse and requests no strenuous physical activities during her session. She also reports onset of upper extremity numbness shortly before the headache started. She says this happens to her several times per year for the last few years, and her primary care physician is not concerned about it. How do you proceed with this patient?
A. Instruct her in self-SNAG exercises
B. Perform myofascial dry needling for tension-type headache
C. Treat patient for migraines with symptom-modulating interventions
D. Refer to emergency department for imaging
Here, we have a case of migraine with aura. In this case, the aura is upper extremity numbness. This is not the most common type of aura, which may be alarming, but she has a long history of this happening and resolving, and her physician knows about it. Now, physicians—like physical therapists—can be wrong, but everything else in this case fits a headache with a migraine, so there are not enough signs to panic and refer to the emergency department. So we should treat her for migraines with symptom-modulating interventions.
Let’s do one last case:
A 56-year-old female patient arrives for initial evaluation and reports that her chief complaint is a migraine. She describes it as diffuse pain in her head that started suddenly this morning while she was working outside. She reports nausea and visual disturbances, and she says this is the worst headache of her life. Which of the following is the most appropriate action for this patient?
A. Treat patient for migraines with symptom-modulation interventions
B. Treat acute headache with thoracic manipulation
C. Perform trigger point dry needling in the cervical and facial musculature
D. Activate emergency medical services
This is another case where you might like more information and might like to do some more testing, but you’ve been given enough information to make the correct decision. The patient reports that she has a migraine, but don’t let that fool you: a lot of people will use the word “migraine” to describe a bad headache. The fact that she describes it as the worst headache of her life—and therefore it’s different from any past migraines she might have had—should sound some alarm bells in your head. Also, the sudden onset is unusual for a migraine, which usually starts more gradually. And the pain is diffuse, which is unusual for migraines, tension-type, cervicogenic, and cluster headaches. You should be suspicious of some red flag conditions like a subarachnoid hemorrhage here and activate EMS.
I think one of the real keys in distinguishing between migraines with auras that involve neurological signs and emergent conditions that have neurological signs is that individuals who have migraines get fairly familiar with their symptoms. If their neurological symptoms are typical of their migraines and their MD is aware, we don’t necessarily have to panic. But if those neurological symptoms are suddenly very different than usual, very severe, or otherwise don’t fit a typical migraine pattern, we should suspect something more serious.
That wraps up this discussion on headaches. I’ll say one more time that there are other types of headaches that the IHS defines that are relevant to physical therapists, including headache attributed to trauma or injury—like in whiplash associated disorder or concussions—and headache attributed to cervical myofascial pain, which is more of a pure trigger point headache, or occipital neuralgia, which is an entrapment of the occipital nerves that innervate the back of the scalp. You can always dive into the 3rd edition of the International Classification of Headache Disorders if you want more info, but I think this podcast covers most of what you need to know about the main types of headaches.
As I wrap up, I want to thank you all for your support this year, and I wish you all success in all your endeavors—but especially with the OCS exam—in this new year.