is less defined (Carvalho et al., 2020). By contrast, cervicogenic headaches, which originate from dysfunction in the upper cervical spine, are often effectively treated by physical therapists. A systematic review by Racicki et al. (2013) found that physical therapy interventions, especially cervical manipulation and mobilization combined with cervicoscapular strengthening, are effective interventions for decreasing cervicogenic headache intensity and frequency. Differential diagnosis of headaches begins with understanding the types of headaches. Types of headaches The International Headache Society (HIS) developed a classification system to help clinicians in the diagnosis and management of headaches (Dale et al., 2020). Per the HIS, headaches are classified as primary or secondary based on the patient’s clinical presentation and associated symptoms. Primary headaches Primary headaches are caused by over activity of or problems with the pain-sensitive structures within the cranium or upper cervical spine. They are not caused by underlying disease or structural problems (Anarte et al., 2019). According to the HIS, primary headaches include: ● Migraine headaches. Secondary headaches are considered symptoms of an underlying or known disease (Anarte et al., 2019) or conditions that affect the nervous system (Dale et al., 2020). These headaches may be attributed to: ● Nonvascular intracranial disorder. ● Substance use or its withdrawal. ● Infection. ● Disorder of homeostasis. ● Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure. ● Psychiatric disorder. ● Trauma or injury to the head and/or neck. ● Cranial and/or cervical vascular disorder. ● Tension-type headaches. ● Cervicogenic headaches. ● Other primary headache disorders. Secondary headaches Understanding whether a headache is primary or secondary helps the therapist determine the origin of the patient’s symptoms, whether a medical referral might be helpful, and whether physical therapy treatment might be helpful. Healthcare consideration: Knowing the differences between a primary and secondary headache is necessary for determining the source of your client’s head pain. A primary headache is caused by dysfunction in the pain- sensitive structures within the cranium or upper cervical spine. Secondary headaches are caused by an underlying or known disease or condition that affects the nervous system, such as an infection or head/neck trauma. Systemic origins of headaches Along with understanding the classification of headaches as primary or secondary, differential diagnosis of headaches involves being aware of the many systems and diagnoses that can cause headaches. This is necessary for determining if referral to a physician is warranted and whether physical therapy might be helpful. Systemic origins of headache include the following.
Self-Assessment Quiz Question #7 Evidence shows that physical therapists are not able to effectively treat all types of headaches. The type of headaches that physical therapists are considered quite
effective in treating is: a. Migraine with aura. b. Migraine without aura. c. Cervicogenic. d. Cluster.
Self-Assessment Quiz Question #8 Which of the following is considered a secondary headache? a. Brain abscess. b. Migraine.
c. Tension-type. d. Cervicogenic.
According to Straube et al. (2019), the onset of primary headaches is age dependent. The onset of migraine headaches is often puberty (Straube et al., 2019). Before puberty, migraines are slightly more common in boys, but with the onset of females’ cyclical hormonal changes, migraines become more common in girls. This difference continues into adulthood, where women are more commonly affected by migraines than are men (Straube et al., 2019). The onset of tension-type headaches is typically in the 20s and rarely after age 50, and they affect women more than men (Pluta et al., 2011). Cluster headaches have their maximal prevalence at 20–40 years of age and affect men more than women (Straube et al., 2019). Evidence-based practice: Age of headache onset can be useful information in differentially diagnosing primary headache types. Migraines typically start in puberty. Tension-type headaches typically start in the 20s and rarely after age 50. Cluster headaches have their maximal prevalence at 20–40 years of age (Straube, 2019).
Cancer Primary neoplasm . The risk of finding a brain tumor in a headache patient is rare. According to Do et al. (2019), it is less than 0.1%, with the majority being present in patients over 50 years of age. Metastases to the brain are highest with lung cancer, breast cancer, and malignant melanoma (Do et al., 2019). Relevant accompanying symptoms include emesis, headache duration less than 10 weeks, atypical headache pattern, pulsating quality and moderate to severe intensity, gait instability, and extensor plantar response (Do et al., 2019).
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