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Differentials for Headaches
New or different HA 50+
HA develops within minutes (thunderclap headache),
inability to move a limb or abnormalities on neurological
examination, mental confusion, being woken by HA,
HA that worsens with changing posture.
HA worsened by exertion /Valsalva manoeuvre visual loss or
visual abnormalities, jaw claudication, neck stiffness, fever,
and HA in people with HIV, cancer or risk factors for
thrombosis.
What are primary and secondary HA and Primary HA are not caused by other disease. Examples are
what causes them?
migraine and tension type). Secondary HA caused by some
other underlying condition.
Cervicogenic HA
AKA: occipital neuralgia.
Causes: can be caused by compression (causing irritation or
injury) of the greater occipital nerve by over-tight neck mms,
osteophytic growth as the nerve leaves the spine, trauma or
tumour. Also diabetes, blood vessel inflammation (vasculitis),
and prolonged neck flexion.
Symptoms: gradual onset of post head, above eye, temporal
pain. Usually unilat.
Who? 20-60 yrs.
Osteopathy? Some evidence osteopathic ttt such as HVT, ST
and MET is effective.
Examinations-MT: observe for altered neck posture,
decreased ROM in Csp, trigger points in s.occipitals, neck and
shoulder mms. Nerve blocks can confirm diagnosis but MRI
shows nothing.
Migraine: cause, symptoms, most likely
Primary HA
people to be effected?
Causes: Vascular origin, facilitated segment in the brain stem.
Trigeminal nerve involved.
Symptoms: prodrome up to 2 days before, aura (visual,
sensory, physical) just before. One sided, throbbing
Can become less sever but more frequent with age.
Who? male: female 1:3. 12% population.
Osteopathy? Some small studies suggest manipulation can
decrease pain intensity and frequency of migraine.
What are the red flags for HA?
Tension type HA.
Primary HA, most common HA.
Causes: associated with stress, mms contraction.
Symptoms: pain on both sides of the head, forehead, temples
or the back on head and/or neck.
Who? 40% population. More common in females. 30-39 age
group most affected.
Osteopathy? Systematic review showed manipulation to be
affective.
Cluster HA.
Primary HA
Causes: mechanism unknown, possible due to ANS affecting
trigeminal nerve, cold weather/alchohol can trigger.
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Symptoms: most severe pain humans report. Upto 3 x day.
ipsilateral lacrimation, rhinorrhea, ptosis
Who? Men more than women. 4:1, 0.1% of population.
Osteopathy? Do not seem to be musculo-skeletal-no evidence
easily available on pubmed…some anecdotal evidence.
Sinus HA
Hypertension HA
Worse am
CA headache
Bleeds cause HA?
Whiplash HA
Secondary HA; hard to distinguish from migraine. Migraines
usually not accompanied by yellow snot! Important to get right
as meds are effective for each type if diagnosed correctly.
Causes: different opinions…some say rarely due to sinusitis;
others that the infection causes the pain.
Symptoms: dull, deep, throbbing pain anteriorly. Face TTP,
worse for sudden mmts and leaning forward. Worse am as
drainage worse.
Who?
Osteopathy? Maryland medical system says: Stretches for the
head and neck/ Relaxation techniques help prevent sinusitis.
Drinking more fluids and using a humidifier
Secondary HA
Causes: best evidence suggests high BP doesn’t cause HA
unless in case of hypertensive crisis (systolic/top number
higher than 180 OR diastolic/bottom number higher than 110)
(heart.org)
Symptoms: generalized or "hairband" type pain. They are
most severe in the morning and diminish throughout the day
Who? Hypertension is more common in men but women have
a higher incidence of headaches
Osteopathy? If we can reduce BP through relaxation advise,
reducing stress, lifestyle advise.
Causes: Symptoms: progressively worse over time worse am,
pain may wake you up. Accompanied by nausea and vomiting.
Headache pain that is relieved by vomiting is a typical
symptom of brain tumour. Straining/ Leaning forward agg.
pain. Not relieved by painkillers.
Who? 2 peaks incidence; childhood, then larger peak in 70.
Osteopathy? No
The headache attributed to Sub-arachnoid Haemorrhage often unilateral, accompanied by nausea, vomiting, disorders
of consciousness and nuchal rigidity ((neck stiffness), and less
frequently by fever and cardiac dysrythmia
Headache attributed to intracerebral haemorrhage
Headache is more frequent and more severe in haemorrhagic
than in ischaemic stroke. It is usually overshadowed by focal
deficits or coma, but it can be the prominent early feature of
cerebellar haemorrhage which may require emergency surgical
decompression.
Osteopathy? No
Causes: C3 facet and its nerve most vulnerable to whiplash
injury.
Symptoms: Pain from the C2–3 facet is referred to the
occipital region but is also referred to the frontotemporal and
periorbital regions.
Osteopathy? The majority of cervicogenic headaches
occurring after whiplash resolve 1 yr. treat as cervicogenic
HA, evidence for myofascial release etc
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Meningitis HA
Glaucoma HA
Causes: Inflammation of meninges caused by infection with
viruses, bacteria, or other microorganisms.
Symptoms: severe headache and neck stiffness, pain on
passive neck flexion. Fever, photophobia and altered mental
status.
Who? Babies, uni students and adults 55+.
Osteopathy? Obviously not.
Examinations- Koernig sign (below pic) and Brudinski’s
(Flexing the patient’s neck causes flexion of the patient’s hips
and knees.)
Causes: Fluid in the eye does not drain properly, or there is
over-production of fluid, which causes increased pressure
within the eye
Symptoms: HA in or around the eyes or the forehead, and
vary in intensity from mild to severe. Nausea and vomiting
also can accompany the headache.
Chronic-slowly develops-peripheral vision affected.
Acute: intense pain, redness of the eye, HA, tender eye
Who? 60+, Hypertension, injury to the eye can cause acute
angle glaucoma.
Encephalitis HA Causes: Encephalitis is an acute inflammation of the brain. Symptoms:HA, fever,
confusion, drowsiness. Neck stiffness.
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TMJ HA
Briefly list other HA and how to
recognise them.
Causes: Dental problems, Trauma
Hormonal changes, Fatigue, Clenching and grinding, Poor
posture.
Symptoms: ‘vice-like grip’. achy, throbbing headache HA in
temples, back of the head/ shoulders. Clenching and grinding
of the teeth, both of which may be TMJ symptoms, produce
mms pain which can cause HA. Displaced disc in the TMJ
may cause pain in the joint referred into the temples, forehead
or neck. Worse am or pm depending on when teeth grinding
occurs.
Who?
Osteopathy? Seems to be treated will good results-SF
masseter, Temporalis, gapping TMJ joint.
Questions: Do you hear popping, clicking or cracking sounds
when you chew? Do you hear a grating sound (like crumpling
of newspaper) when you chew?
Thunderclap HA-Severe and sudden-onset. It is defined as a
severe headache that takes seconds to minutes to reach
maximum intensity. It can be indicative of a number of
medical most importantly subarachnoid hemorrhage problems
Carbon monoxide exposure-frontal HA all the time, present
in winter.
Caffeine withdraw-starts behind the eyes and then moves up
the front of the head. Acute caffeine abstinence increased brain
blood flow.
Coital cephalalgia “sexual headaches" occurs at the base of
the skull, extremely severe and sharp pain behind the eyes.
Usually men early 20’s, or 35-40 , 1% population.
Temporal arteritis: HA is persistent but often worse at night
and sometimes severe, in a patient over 50 who does not feel
entirely well. It may be accompanied by marked scalp
tenderness.