[Editor’s Note: This piece originally appeared as part of
Pain Management’s coverage of PAINWeek 2011. Pain Management is a sister publication of
When patients complain of frequent and severe headaches, health care providers have a natural tendency to assume that classic headache syndromes like migraine are indeed the problem, particularly when there’s no clear trigger to suggest the pain is coming from somewhere else.
But such assumptions usually prove to be mistaken. In up to three-quarters of all cases, pathologies elsewhere in the head and neck refer pain that only seems like a classic headache. Unfortunately, the real problems—most often micro-withdrawal from chemicals like caffeine or pathologies in the neck called cervicogenic headache—are often missed, thanks to the lack of diagnostic criteria, diagnostic training, and limited time during physician visits.
“Many problems in the neck and shoulders can produce severe head pain that patients interpret as headaches. The real problem may be in the bones, the muscles, the ligaments, the nerves, or elsewhere—but you can learn to spot almost any of them if you learn the proper questions to ask and are willing to ‘lay hands’ on your patients,” says Norman Harden, MD, who spoke about the underlying principals, diagnostic techniques, and rational therapies during the PAINWeek 2011 conference, held Sept. 7-10 in Las Vegas, Nevada.
“Not only are a detailed history and physical examination the best way to begin diagnosing problems in the neck and shoulders, it’s also the only accepted way to identify more traditional headache diagnoses. You might be totally sure it’s a traditional headache diagnosis, and that the neck has nothing to do with it. But most doctors would be surprised by how often that is incorrect. You can save a patient from years of counterproductive therapy by taking 10 seconds to examine the patient’s neck,” he said.
Harden, who runs the Center for Pain Studies at the Rehabilitation Institute of Chicago (www.ric.org/research/centers/pain/index.aspx
), has spent decades dealing with upper body injuries that present as head pain. Unfortunately, few physicians realize how common such problems are because only a small minority of these cases ever gets properly diagnosed. “A fair percentage of people who have undergone decades of treatment for migraines and cluster headaches actually have neck pathology or tempromandibular joint dysfunction,” said Harden.
When making a diagnosis, physicians must do far more to gather thorough patient histories. The more physicians know about patients and the longer they spend talking about how and when the pain appears, the greater the chance that some tidbit of information will reveal the true problem. Even if that information is never discovered, the effort pays off when it comes time to devise treatments that reflect the needs of each individual patient.
The other trick to diagnosing cervicogenic headaches, according to Harden, is the physical examination. “Touching patients seems antiquated to many younger doctors, who think it vaguely unscientific. But in most cases, a good hands-on exam beats any x-ray or MRI, and that’s why I’m going to spend some time outlining the principals of an effective exam,” he said.
Within just a few minutes, a skilled examiner can measure dozens of potentially important physical points, such as ligament, tendon, or muscle trigger points; postural or functional limitations and pain; characteristics of peripheral and central sensitization; and jaw and tooth pain.
In his presentation, Harden discussed treatment options for some of the most common causes of cervicogenic headaches. “Those treatments will vary widely, but must be based on a thorough understanding of the potential underlying mechanisms that can only be acquired by good old school diagnostic technique,” he noted.
In some cases, the treatment can be very simple, such as instructing patients to sit up straight at work, drink less caffeine, or get more sleep. In many other cases, however, the underlying cause of the pain cannot be fixed, and the provider must manage the pain as effectively as possible. Physicians dealing with cervicogenic headaches must generally go beyond medication and bring in additional tools, including biofeedback, meditation, and physical and occupational therapy. “Cervicogenic headaches will occasionally respond to the same medications as migraines, but different medications and treatments should be considered, based on a mechanistic diagnosis,” Harden said.