By: Oron Fiksel, DPT, CFMT, OCS, Cet-DN, COMT, FAAOMPT
Lillian S. Wells Foundation Institute of Sports Performance and Orthopedic Therapy (iSPORT) at Holy Cross Health
A variety and overlapping symptoms in the different types of headaches (HAs) have led to a significant number of misdiagnosis and therefore incorrect treatments of chronic HA patients. The following aims to provide clinicians with general guidance on the differential diagnosis of patients who suffer from HAs.
There are three types of headaches most seen in outpatient clinics are: cervicogenic (CHA), tension-type (TTH) and migraine headaches. Often these HAs present with overlapping symptoms, which makes the treatment challenging.
Cervicogenic Headaches
CHA may affect any age or gender but have a higher prevalence in patients over the age of 50. CHA is characterized by episodic symptoms starting after trauma to the neck or head. However, chronic accumulative mechanical stress to the cervical spine may start a degenerative cascade that results in CHA.
The most common features of CHA are:
1) A headache on one side of a patient’s head that is aggravated by posture, neck movement or by suboccipital external pressure.
2) Reduced range of motion in a patient’s neck.
3) Pain in the shoulder, neck, or arm on the same side of the body as the headache.
4) The pain is described as moderate to severe and is non-throbbing in nature with variable durations.
Autonomic symptoms such as photophobia, phonophobia, nausea and vomiting are less common than when a patient is suffering from a migraine.
Tension-type Headaches
TTH is more common in women and may present at all ages with increased prevalence between the ages of 30-50. Symptoms are characterized by both feeling pain on both sides on your head and dull, mild-moderate, non-pulsating pressure pain that is not aggravated by physical activity.
Episodes occur less than once per month and may last between 30 minutes and seven days. As opposed to CHA and migraine, there are no symptoms of nausea or vomiting. It is rare for photophobia or phonophobia to occur.
Migraine Headaches
Migraine HA with or without aura affects females more than males with the highest prevalence between the ages of 18-44 years old. A hormonal component has been strongly suggested as a trigger in females.
Migraines with aura refers to visual and sensory symptoms followed by moderate to severe pulsating headaches on one side of the head that last between four to 72 hours. Migraine HAs are often accompanied by nausea, vomiting, photophobia and phonophobia. Episodes are aggravated by routine physical activity.
Migraines without aura present similarly to migraines with aura, but without the visual and sensory symptoms. Chronic migraines are considered to consist of more than eight episodes per month.
The Impact of Headaches on Daily Functionality
Migraines and CHA typically lead to greater daily functional impact than TTH. Due to the severity of pain and symptoms, migraine patients often suffer from multiple days of debilitation which affect their ability to work, engage in social life, drive and, in severe cases, basic activities of daily living. CHA patients are similarly impacted due to the varying duration of symptoms, moderate pain and restrictions in range of motion.
Prognosis
A few potential prognostic factors for chronic headaches have been suggested. Moderate quality evidence showed that depression, anxiety, medication overuse, poor sleep, high stress, low-self efficacy and low expectations of treatment suggest poor prognosis.1 Low-quality evidence showed that being employed, older age of onset and higher severity of headaches had favorable outcomes. High frequency of episodes and onset younger than 20 years of age were associated with poor outcomes for migraines.2
Poor outcomes for TTH were higher frequency of episodes, co-existing migraine, not being married and sleep deprivation. CHA prognosis is rarely discussed in medical literature. However, manual therapy publications indicate good outcomes when treatments combine manual therapy, specific exercises, postural education and lifestyle changes.3,4
One systematic review showed positive outcomes in pain intensity, frequency and duration of CHA, TTH, migraine and mixed HA with physical therapy treatment.5 Specifically, manual therapy and exercises have demonstrated good outcomes for all three headache types. In general, CHA has the best prognosis for orthopedic manual therapy treatment, followed by TTH and finally migraine due to differences in pathophysiology underlying each type of headache.6,7,8
Considering these psychosocial components are modifiable, many chronic headache patients can have positive outcomes if appropriate treatment and education is provided. However, clinicians should be aware of poor outcome predictors and the difficulty of progressing patients with central sensitized nervous symptoms with chronic headaches.
Oron Fiksel is a Fellow and Doctor of Physical Therapy in the residency program at the Lillian S. Wells Foundation Institute of Sports Performance and Orthopedic Therapy (iSPORT) at Holy Cross Health, South Florida’s premier state-of-the-art sports medicine program providing evidence-based education, training and management. He is conducting a case series study at Holy Cross Health as part of his Doctor of Science dissertation to describe the outcomes of patients who suffer from chronic HAs. Participating patients will be treated with a combination of upper cervical manipulation and exercises, as well as the elimination of processed carbohydrates and dairy products. Adult patients who suffer from chronic headaches who are interested in participating in this study should email him at Oron.fiksel@holy-cross.com or call (201) 736-2741.
- Probyn K, Bowers H, Caldwell F, et al. Prognostic factors for chronic headache: A systematic review. Neurology. 2017;89(3):291-301. doi:10.1212/WNL.0000000000004112
- Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Prognosis of migraine and tension-type headache: a population-based follow-up study. Neurology. 2005;65(4):580-585. doi:10.1212/01.wnl.0000172918.74999.8a
- Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011;6(3):254-266.
- Núñez-Cabaleiro, P, Leirós-Rodríguez, R. Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review. Headache. 2022; 62: 271– 283. doi:10.1111/head.14278
- Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis [published correction appears in Cephalalgia. 2016 Jul;36(8):819-20]. Cephalalgia. 2016;36(5):474-492. doi:10.1177/0333102415597889
- Satpute K, Bedekar N, Hall T. Headache symptom modification: the relevance of appropriate manual therapy assessment and management of a patient with features of migraine and cervicogenic headache – a case report. J Man Manip Ther. 2020;28(3):181-188. doi:10.1080/10669817.2019.1662637
- Jull GA, Niere KR. The cervical spine and headache. Clinical Science for Manual Therapy of the Spine. Saunders Elsevier; 291-304.
- Bayraktutan OF, Demir R, Ozel L, Ozdemir G, Ertekin A. Prevalence of Tension-Type Headache in Individuals Aged between 18-65 Years in the Eastern Parts of Turkey. Eurasian J Med. 2014;46(2):78-83. doi:10.5152/eajm.2014.20
