Case 1

School Of Health Sciences

REHA2167
Chiropractic 5
Spinal Syndromes 2

Case 1
A 45-year-old computer programmer
presents with right-sided headache and
facial pain.

RMIT University

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Case 1 History findings

Right occipital and frontal regions, behind the eye on the right
Right temporal and over right cheek bone
Gradual onset past 4-5 months.
Constant dull ache in quality 4/10
Occasional throbbing pain only when headache most severe 8/10
The headache is present on waking most mornings. Does not wake the patient.
Worse towards end of the day at work.
Aggravated by working with neck flexed for long period and at the computer
Relieved with Panadol, rest
She reports some neck discomfort / stiffness.
She experiences occasional mild nausea but only when the headache is at its worst. No
vomiting.
Previous medical history:
Whiplash injury 6 months earlier - driver, hit on right side car. No direct blow to her head.
Takes Coversyl medication for mild hypertension.
Systems review:
No history recent nasal congestion or upper respiratory infection
No double vision, dizziness, loss of balance, memory changes or difficulty in concentration

RMIT University

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Age & Gender

Age no red flags
Female (consider migraine)

RMIT University

Slide 4

Onset
Unknown
Insidious
Gradual onset past 4-5 months (recurrent &
does not appear to be progressive although
this not ascertained from history given so
must confirm with patient, but this suggests
BENIGN & NOT MALIGNANT headache as
well as present for number of months)
Whiplash injury 6 months earlier - driver, hit on
right side car. No direct blow to her head
(consider cervicogenic headache)
RMIT University

Slide 5

Location of headache
Unilateral (consider migraine, cervicogenic
headache, sinusitis, myofascial pain
syndrome)
Location
Right occipital and frontal regions, behind the
eye on the right (consider migraine,
cervicogenic headache, myofascial pain
syndrome)
Right temporal and over right cheek bone
(consider migraine, cervicogenic headache)
RMIT University

Slide 6

Quality of headache
Constant dull ache in quality (consider
migraine, cervicogenic headache,
sinusitis, myofascial pain syndrome)
Occasional throbbing pain only when
headache most severe 8/10 (consider
cervicogenic headache) Rules out
migraine

RMIT University

Slide 7

Intensity of headache
Constant dull ache in quality 4/10
(consider cervicogenic headache,
sinusitis, myofascial pain syndrome)

RMIT University

Slide 8

Periodicity of headache
The headache is present on waking most
mornings. Does not wake the patient
(consider migraine, cervicogenic
headache, sinusitis)
Worse towards end of the day at work
(consider migraine, cervicogenic
headache, myofascial pain syndrome)

RMIT University

Slide 9

Aggravation of headache
Aggravated by working with neck flexed
for long period and at the computer
(consider cervicogenic headache,
sinusitis, myofascial pain syndrome)

RMIT University

Slide 10

Relief of headache
Relieved with Panadol, rest (consider
cervicogenic headache, myofascial
pain syndrome). Need to ascertain from
patient if rest includes rest in darkened
& silent room to rule out migraine.

RMIT University

Slide 11

Associated symptoms
She reports some neck discomfort /
stiffness (consider migraine,
cervicogenic headache, myofascial
pain syndrome)
She experiences occasional mild nausea
but only when the headache is at its
worst. No vomiting (consider
cervicogenic headache, myofascial
pain syndrome). Rules out migraine &
sinusitis.
RMIT University

Slide 12

Systems review
No history recent nasal congestion or
upper respiratory infection Rules out
sinusitis.
No double vision, dizziness, loss of
balance, memory changes or difficulty in
concentration Rules out RED FLAGS re:
neoplasia, infection, hematoma,
cardiovascular injury, etc
RMIT University

Slide 13

Hypertension headache
Rule out:
Bilateral
Pulsating
Precipitated by physical activity
BP > 160/120 mmHg
Headache develops during hypertensive crisis
Headache resolves within 1 hour after
normalisation of BP
Little evidence that moderate hypertension
predisposes to headache
RMIT University

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Extra questions
Do you experience any unusual
sensations in your eyes, such as
flashing lights?
Does light hurt your eyes?
Do you need to lie down in a darkened,
silent room to help relieve your
headache?
Do any of your family suffer from
headache? If so, what type of
headache?
RMIT University

Slide 15

Differential Diagnosis
1.
2.
3.
4.

Cervicogenic headache
Migraine headache
Myofascial pain syndrome
Sinus headache

RMIT University

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Physical examination - BP
Blood pressure (right seated) 145/85
Rule out hypertensive headache
Confirms differential diagnoses

RMIT University

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Physical examination - ROM

Left rotation decreased by 20%
Consider cervicogenic headache,
myofascial pain syndrome
Rules out migraine, sinus headache

RMIT University

Slide 18

Physical examination - Palpation

Palpation of a tight band in right SCM

reproduces pain over the right eye
Consider myofascial pain syndrome
Palpation of the right upper cervical region
and suboccipital muscles reproduces some
of the pain in the right frontal region
Consider cervicogenic headache, myofascial
pain syndrome
Spinal joint restriction C2 C3 (RP/PRS)
Consider cervicogenic headache
RMIT University

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Physical examination Orthopaedic Tests

Maximal cervical compression on the

right produces (local) pain in the right
upper cervical region
Consider cervicogenic headache
Cervical Kemps test produces (local)
pain in the right upper cervical region
Consider cervicogenic headache

RMIT University

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Physical examination Motion Palpation

Spinal joint restriction C2 C3

(RP/PRS)
Consider cervicogenic headache

RMIT University

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Physical examination Neurological

No upper motor neurone signs

Rules out RED FLAGS re: neoplasia,
infection, hematoma, cardiovascular
injury, etc

RMIT University

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Migraine headache
Rule out by history findings
No evidence:
Pulsatile
Severity (pain 4/10)
Pain-free periods (constant dull ache)
Nausea (only occasional)
Vomiting

Rule out as pain relieved by panadol

RMIT University

Slide 23

Sinus headache
Rule out by history findings:
Location of pain
Periodicity of pain
Associated symptom of occasional nausea

Most importantly, no recent history of

nasal congestion or URTI

RMIT University

Slide 24

Myofascial pain syndrome

Rule out by history findings:

The headache is present on waking most
mornings. Does not wake the patient
Occasional throbbing pain only when
headache most severe 8/10

Most importantly rule out by physical

examination findings which suggest
cervicogenic headache
RMIT University

Slide 25

Working diagnosis
Chronic Cervicogenic Headache

RMIT University

Slide 26

Cervicogenic headache

Confirmed by history:

Unilateral
Location
History of injury
Constant dull ache
Present on waking but does wake the patient
Aggravated by working with neck flexed for long
period and at the computer
Relieved with Panadol, rest
She reports some neck discomfort / stiffness
No nausea, vomiting (some nausea only when
headache severe)
RMIT University

Slide 27

Cervicogenic headache

Confirmed by physical examination findings:

Restriction of cervical ROM

Cervical compression gives localised pain in the joint

Reproduction of headache on palpation of neck structures

Palpation of the right upper cervical region and suboccipital

muscles reproduces some of the pain in the right frontal region

Motion palpation reveals fixated vertebral joints in upper

cervical spine

Maximal cervical compression on the right produces (local) pain in

the right upper cervical region.
Cervical Kemps test produces (local) pain in the right upper
cervical region

Spinal joint restriction C2 C3 (RP/PRS)

Neurological assessment

NAD
RMIT University

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