Question What type of headache best explains this client’s symptoms? Discussion Although the client has headaches that start with neck pain, the clinician concluded that this was a migraine headache. Although there were some positive neck findings, the therapist thought the suboccipital muscle tenderness could be due to the patient’s forward head posture. The craniocervical test was negative and although the flexion–rotation test revealed decreased rotation at C1–C2, this is likely incident, as the preponderance of find - ings indicate migraine headaches. This includes the symptoms of light and sound sensitivity and nausea. The therapist completed postural education with the client and referred her to her primary care physician for further evaluation and possible pharmacologi- cal intervention. Case Study: Jane Taylor A 64-year-old-woman presents with a four-week history of daily right frontotemporal headaches that she describes as aching and throbbing of moderate intensity. Prior to this recent onset, she had only very occasional mild headaches. Past medical history is significant for hypothyroidism, hyperlipidemia, polymyalgia rheu- matica, and degenerative disc disease at C5–C6. She does have intermittent, mild chronic posterior neck pain that she manages effectively with rest and ice. Cervical range of motion was slightly limited but within functional limits with right side bend and rota- tion equal to left. Neurological exam was normal. Question 1. What headache red flag is present in this patient’s history? 2. What conditions might explain this client’s symptoms? Discussion The red flag item in this client’s case is the sudden onset of head - ache in a client over 50 years of age. A workup by her doctor revealed an elevated erythrocyte sedimentation rate (ESR), which is an indication of inflammation. Temporal arteritis is common in clients with polymyalgic rheumatica. This patient did not have tenderness with palpation of the temporal artery but, given her medical history, the doctor ordered a biopsy, which revealed nec- rotizing arteritis. She was started on prednisone and her headache was gone within two days.
Self-Assessment Quiz Question #21 The craniocervical flexion test is used to measure: a. C1–C2 flexion range of motion. b. C2–C3 flexion range of motion. c. Deep cervical flexor muscle strength. d. Superficial cervical flexor muscle strength. Self-Assessment Quiz Question #22
Which type of headache is accompanied by a sense of agita- tion or restlessness that often manifests itself in an ability to lie down? a. Migraine. b. Tension-type. c. Cluster. d. Cervicogenic. Case Study: Ms. Margaret Moore Ms. Margaret Moore is 35-year-old full-time office manager who presents to physical therapy with complaints of headache. She is 64 inches tall and weighs 127 pounds. Her headaches occur two to three times a week, almost always in the late afternoon when she is rushing to pick up her two children from daycare and make dinner. Her symptoms start on the left side of her neck and, with time, increase in intensity and spread to both the left and right temporal areas. Light and noise sensitivities are present and oc- casionally nausea. The headache is gone when she wakes up the next day. Her past medical history includes two Caesarean surger- ies, seasonal allergies, and right anterior cruciate ligament repair. Examination reveals forward head posture with nearly full, sym- metrical cervical range of motion. There is palpable tightness in bilateral scalene and levator scapulae muscles. Tenderness is present in bilateral suboccipital muscles. There is no palpable ten- derness along the cervical spinous or facet joints. Rotation is sym - metrical with the flexion–rotation test but limited approximately 10 degrees on each side. There is no weakness present in the deep cervical muscles as revealed via a normal craniocervical flex - ion test.
CERVICAL SPINE DIFFERENTIAL DIAGNOSIS
Introduction Neck pain is common, with estimates of 30%–50% of adults expe- riencing it in any given year (McCartney et al., 2018). It is consid- ered multifactorial in nature, with many systemic and musculoskel- etal causes (Kazeminasab et al., 2022). Neck pain has a tendency to becoming chronic, so accurate diagnosis and intervention at early onset is critical. According to Raney et al. (2009), over one- third of patients with neck pain will develop chronic symptoms lasting over six months. Neck/shoulder pain and neck/upper back pain often occur together, making differential diagnosis more dif- ficult (Cavallaro Goodman et al., 2018). Healthcare consideration: The fact that neck pain has a ten- dency toward chronicity makes differential diagnosis and ef- fective treatment of acute neck pain important. Chronic neck pain increases disability, with accompanying lower quality of life and loss of productivity (Hoy, 2014). It also causes an increase in economic burden. Physical therapists can help decrease the chronicity of acute neck conditions by diligently attending to the presence of red and yellow flags and expertly honing their differential diagnosis knowledge and skills. Traumatic and degenerative conditions of the spine are the major primary causes of neck pain (Cavallaro Goodman et al., 2018). This includes whiplash syndrome and arthritis. A history of falls,
motor vehicle crashes, or domestic violence should be explored. Referred pain to the arm may be a cause of local biomechanical dysfunction such as disc disease, but systemic origins of referred pain are also possible (e.g., infection or pulmonary disorders). Rheumatoid arthritis often affects the cervical spine and causes several significant problems (Heick et al., 2023). Effective management of cervical issues begins with effective di- agnosis. Systemic and viscerogenic sources of pain must be elimi- nated and musculoskeletal or neuromuscular origins confirmed. A serious underlying cause of neck pain should always be consid- ered and is more likely in people presenting with new symptoms before age 20 years or after age 55 years, weakness involving more than one myotome, or loss of sensation involving more than one dermatome (McCartney et al., 2018). Self-Assessment Quiz Question #23 What percentage of neck pain patients tend to develop chronic symptoms? a. 5%.
b. 10%. c. 25%. d. 33%.
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