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Diagnostic work-up of an elderly patient with unilateral head and neck pain. A case report
Manual Therapy 18 (2013) 598e601
Contents lists available at SciVerse ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Diagnostic work-up of an elderly patient with unilateral head and neck pain. A case report Willem De Hertogh a, c, *, Peter Vaes c, d, Jan Versijpt b a Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, D.S.121, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgium b Neurology Department, University Hospital Brussels, Brussels, Belgium c Department of Physiotherapy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium d Department of Manual Therapy, Faculty of Medicine and Pharmacology, Vrije Universiteit Brussel, Brussels, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 May 2012 Received in revised form 9 August 2012 Accepted 31 August 2012
Headache patients frequently contact physiotherapists and manual therapists. In case of elderly patients with unilateral headache, neck and facial pain clinical practice guidelines recommend further referral for medical investigation to exclude red flags. The present patient was seen in a multidisciplinary headache clinic. He was referred by the neurologist (headache specialist) for physiotherapeutic assessment after screening for red flags, including giant cell arteritis (GCA). After first assessment, GCA was considered unlikely, since the sedimentation rate, as a marker for inflammation, was only slightly elevated. The purpose of the referral was to exclude cervicogenic headache (CEH) and to explore physical treatment as a therapeutic option. Physiotherapeutic assessment consisted of a history taking on CEH signs (Sjaastad criteria, 1998), followed by cervical spine assessment including tests for neck mobility, joint pain, and endurance of the short neck flexors. The patient’s history revealed no specific signs of CEH and cervical spine assessment was negative. In consultation with the neurologist, the diagnosis of CEH was abandoned. Since palpation of the temporal artery proved to be painful, laboratory examination and biopsy of the temporal artery were thereafter performed, this time revealing GCA. Appropriate treatment (high dose steroids) was initiated promptly, with a good clinical evolution. The presented case shows the potential of a multidisciplinary collaboration in the clinical diagnostic work-up of patients with head and neck pain. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Headache Diagnosis Physiotherapeutic assessment Red flag
1. Introduction Unilateral headaches can be a challenging diagnostic issue. The most common unilateral headache is migraine. It occurs in approximately 10% of the population (year-prevalence). Reports of the prevalence of cervicogenic headache (CEH) vary widely ranging from 2.2 up to 4.1% (Sjaastad and Bakketeig, 2008; Antonaci and Sjaastad, 2011). Other strictly unilateral headache types like trigeminal autonomic cephalalgias (e.g. cluster headache) are very rare (Sjaastad and Bakketeig, 2007; Obermann and Katsarava, 2008). Although distinct characteristics can be identified, unilateral headaches can be challenging due to the overlap of diagnostic criteria where, moreover, misdiagnosis can lead to delayed appropriate
* Corresponding author. Department of Physiotherapy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium. E-mail address: [email protected] (W. De Hertogh). 1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2012.08.008
treatment (Yi et al., 2005). This clinical overlap can be explained by a common pathophysiological pathway. Indeed, convergence of input from the trigeminal nerve and from the upper cervical spine occurs in the caudal part of the spinal trigeminal nucleus. This convergence can lead to referred pain in the head from an upper cervical nociceptive source (Piovesan et al., 2001). The opposite is equally true: an intracranial nociceptive source can give rise to referred cervical pain (Bartsch and Goadsby, 2003). According to clinical guidelines, specialist referral for further assessment is recommended when red flags are suspected. A new headache in patients aged over 50 is considered a red flag where giant cell arteritis (GCA) needs to be ruled out. This case report describes a patient who was seen by a neurologist (headache specialist), who referred the patient for physiotherapy assessment. The intention is to illustrate the clinical diagnostic process of an elderly patient with unilateral head and neck pain and illustrate the potential value of a multidisciplinary collaboration.
W. De Hertogh et al. / Manual Therapy 18 (2013) 598e601
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lacrimation and redness of the eye next to rhinorrhea were slightly present. Previous treatment was purely symptomatic and consisted of paracetamol for pain relief. Medical history revealed polyarthrosis, sinus surgery, depression, obesity and arterial hypertension. Given the unclear etiology in a patient with both head and neck pain, the patient was referred to the multidisciplinary evaluation where patients are assessed by both the neurologist and physiotherapist. 2.1. Assessment by the neurologist
Fig. 1. Body chart indicating the location of the patients complaints (lateral view).
2. Case description A 62-year old man consulted a headache specialist because of a strictly left-sided neck pain, headache and facial pain (See Figs. 1 and 2 ). This unremitting pain had been present for two months. The pain was perceived as located in the left suboccipital and neck region, radiating to the ipsilateral head and facial region. No specific moment of onset could be specified neither could a specific trigger be identified. It was a continuous pain, which seemed to increase when lying down. Routine physical activity appeared to diminish headache intensity. Accompanying symptoms such as nausea, vomiting, photo- and phonophobia were all absent. Ipsilateral
Unilateral head and neck pain can be present in various headache types, including migraine without aura, trigeminal autonomic cephalalgias (in this case in particular hemicrania continua since we are dealing with an unremitting headache), and CEH. Consequently, these were listed as working diagnoses. The diagnostic criteria of the International Headache Society (IHS) for migraine and hemicrania continua are applied and listed in Table 1 (International Headache Society, 2004). Caution is required in patients above 50 years of age complaining of a new headache. This might potentially be a GCA or temporal arteritis. When misjudged, it can lead to permanent visual loss or other neurologic or systemic complications. An overview of red flags in headache patients is listed in Table 2. Laboratory tests were performed, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) next to imaging such as ultrasound of the temporal arteries (Kale and Eggenberger, 2010). The ESR is a highly sensitive test, and is the most useful to rule out GCA (Smetana and Shmerling, 2002). Laboratory tests revealed an ESR of 44 mm/h (max 30 mm/h) and a CRP of 44.8 mg/L (max 5 mg/L). These values indicate a mild inflammatory state, but ESR remained below the threshold of 50 mm/h, as defined by the American College of Rheumatology (Hunder et al., 1990). Consequently, temporal arteritis was not withheld at this stage and a further work-up was performed. The patient’s headache was unilateral, but was not aggravated by routine physical activity, and no associated symptoms like photo- or phonophobia were present. Also, the headache had a rather constant character. Consequently, the diagnosis of migraine was considered less likely (yielding only ‘probable migraine’ according to the IHS criteria).
Fig. 2. Body chart indicating the location of the patients complaints (frontal and dorsal view).
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W. De Hertogh et al. / Manual Therapy 18 (2013) 598e601 Table 1 Diagnostic criteria of migraine without aura and hemicrania continua (International Headache Society, 2004). Migraine without aura
Hemicrania continua
Headache presents in attacks, lasting 4e72 h if untreated or unsuccessfully treated Headache has at least two of the following characteristics: unilateral location pulsating quality moderate or severe pain intensity aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs) During an attack at least one of the following: nausea and/or vomiting photophobia and phonophobia
Continuous headache, without pain-free periods
Not attributed to another disorder
Trigeminal Autonomic Cephalalgias (TAC) form a group of mostly strictly unilateral headache types of which the best known is cluster headache characterized by excruciating headache associated with at least one autonomic feature like restlessness, ipsilateral lacrimation, conjunctival injection, nose obstruction or rhinorrhea. Hemicrania continua is the only member of this group where patients have unremitting headache. Since hemicrania continua is strictly responsive to indomethacin, this was prescribed for the patient. The patient took it up to a dose of 150 mg but it appeared to be ineffective so consequently, the diagnosis of hemicrania continua was abandoned. 2.2. Physiotherapeutic assessment This consisted of a history taking focusing on CEH characteristics as described by Sjaastad et al. (1998) (see Table 3). These criteria have good clinimetric properties (Vincent, 1998; van Suijlekom et al., 1999; Antonaci et al., 2001; Huijbregts, 2010) and are more frequently used than the IHS criteria (Huijbregts, 2010). The patient described his headache as a sidelocked unilateral headache, primarily located occipitally, starting in the neck. He perceived his cervical mobility as limited. No ipsilateral shoulder or arm pain was reported. No mechanical headache triggers such as maintained postures or repeated movements were identified. In addition to the history taking, a cervical spine assessment was performed. It included an assessment of the cervical range of motion, joint pain on palpation and endurance of the short neck flexors. Cervical range of motion was assessed actively for flexion/ extension, rotation and side bending. Passive tests rating pain provocation (recognizable headache) and mobility were performed Table 2 Clinical signs indicative of possible underlying pathology (red flags) Adapted from Huijbregts (2010) and Joubert (2005). Clinical sign
Suspected underlying pathology
New headache in patients over 50 years of age
Giant cell arteritis/brain tumor Intracranial hemorrhage Subarachnoid hemorrhage
Headache onset after trauma Severe headache of sudden onset (thunderclap headache or first and worst headache) Persistent and/or progressive headache Headache associated with illness, fever and neck stiffness Focal signs or symptoms Headache triggered by changes in posture
Brain tumor Meningitis Stroke Cerebrospinal fluid dysfunction
Headache has all of the following characteristics: unilateral pain without side-shift daily and continuous, without pain-free periods moderate intensity, but with exacerbations of severe pain
At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: conjunctival injection and/or lacrimation nasal congestion and/or rhinorrhea ptosis and/or miosis Complete response to therapeutic doses of indomethacin Not attributed to another disorder
(De Hertogh et al., 2007). In addition the flexion-rotation test (Hall and Robinson, 2004; Ogince et al., 2007) was performed, given its high diagnostic value for CEH. Since cervical spine dysfunctions are common and not headache-specific in elders (Uthaikhup et al., 2009), an additional advantage of assessing rotation is that it allows to make lefteright comparisons. The muscle endurance of the short neck flexors was assessed as first described by Grimmer (Grimmer, 1994). This test has shown to have good clinimetric properties (de Koning et al., 2008). It has been used in previous studies addressing physical impairments in CEH (Dumas et al., 2001) and in recent clinical trials dealing with headache treatment (Castien et al., 2011). Cervical mobility appeared to be limited, but this was considered as normal for his age. No lefteright differences during the rotations could be observed. Joint palpation revealed no relevant pain provocation (i.e. no provocation of the recognizable headache). The Table 3 Criteria for cervicogenic headache (Sjaastad et al., 1998). Major criteria of cervicogenic headache Symptoms and signs of neck involvement: (a) precipitation of head pain, similar to the usually occurring one: (1) by neck movement and/or sustained awkward head positioning, and/or: (2) by external pressure over the upper cervical or occipital region on the symptomatic side (b) restriction of the range of motion (ROM) in the neck (c) ipsilateral neck, shoulder, or arm pain of a rather vague nonradicular nature or, occasionally, arm pain of a radicular nature. Confirmatory evidence by diagnostic anesthetic blockades Unilaterality of the head pain, without side-shift Head pain characteristics - moderate-severe, nonthrobbing, and non-lancinating pain, usually starting in the neck - episodes of varying duration, or fluctuating, continuous pain Other characteristics of some importance - only marginal effect or lack of effect of indomethacin - only marginal effect or lack of effect of ergotamine and sumatriptan - female sex - not infrequent occurrence of head or indirect neck trauma by history, usually of more than only medium severity. Lesser importance Various attack-related phenomena, only occasionally present, and/or moderately expressed when present: - nausea - phonophobia and photophobia - dizziness - ipsilateral “blurred vision” - difficulties on swallowing - ipsilateral edema, mostly in the periocular area
W. De Hertogh et al. / Manual Therapy 18 (2013) 598e601
muscle endurance of the short neck flexors was not impaired (patient was able to maintain the flexed and chin-tucked position for 40 s). The lack of positive findings in history taking and physical examination made CEH an unlikely diagnosis, which was discussed with the neurologist. 2.3. Additional assessment by the neurologist Palpation of the temporal artery revealed tenderness over the left but also less pronounced over the right temporal artery. This clinical sign is indicative for giant cell arthritis, and appropriate additional tests were scheduled. The laboratory examination this time showed an ESR of 66 mm/h, CRP-value was 58.3 mg/L. Both are indicative of an inflammatory process and a biopsy of the temporal artery was scheduled which confirmed the diagnosis of GCA. Steroids (methylprednisolon at an initial dose of 64 mg) were promptly initiated achieving a swift recovery with good response to the headache. Steroids were continued and slowly tapered over the following months. The patient’s condition remained well until the last follow-up (nearly one year after diagnosis). 3. Discussion The present case report describes an elderly patient with unilateral headache, facial and neck pain. This combination of symptoms is frequently encountered by physiotherapists. The aim of the present case description was manifold. First, the purpose was to illustrate that unilateral headache and neck pain occurs in various headache types and is not limited to CEH. Also, overlap between headache types can occur. This was also documented by Yi et al. (2005) who found cervicogenic factors in previously diagnosed migraine patients. The second purpose was to elaborate on the diagnostic criteria of relevant unilateral headache types, and to mention the diagnostic criteria of migraine, hemicrania continua, CEH and temporal arteritis. In various countries, patients have direct access to physiotherapy. Hence, it is mandatory that physiotherapists recognize relevant headache types and select those they can treat and distinguish them from those which need further referral to a physician. The presented case was referred by a neurologist, after screening for red flags. Hence, the third aim was to illustrate that caution for serious underlying pathologies always remains necessary. In case of negative findings from a physiotherapeutic assessment, consultation of the referring doctor is recommended. Fourth, the additional value of a physiotherapeutic assessment in the clinical diagnostic process of headache patients was illustrated. Clinicians are biased by their professional background. The multidisciplinary approach contributed here to the early abandonment of CEH in the list of potential diagnoses. No classic additional CEH tests such as diagnostic blocks were scheduled. This probably has shortened the time to diagnosis. Since time is an important factor in the case of GCA with its known potential major complications like permanent vision loss and neurovascular complications, this was a clinically relevant contribution. 4. Conclusion Headache and neck pain are frequently encountered by physiotherapists, and is not restricted to the diagnosis of CEH. Especially in countries with direct access to physical treatment, knowledge of red flags is mandatory. Caution remains necessary even after screening of the patient by a physician, since medical conditions
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can evolve. Physiotherapists can as such substantially contribute to the clinical diagnostic work-up of headache patients. Acknowledgments Willem De Hertogh is partially supported by a research grant from the UZ Brussel Willy Gepts Fund 2009. References Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia 2001;21(5):573e83. Antonaci F, Sjaastad O. Cervicogenic headache: a real headache. Current Neurology and Neuroscience Reports 2011;11(2):149e55. Bartsch T, Goadsby PJ. Increased responses in trigeminocervical nociceptive neurons to cervical input after stimulation of the dura mater. Brain 2003;126(Pt 8): 1801e13. Castien RF, van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia 2011;31(2):133e43. De Hertogh WJ, Vaes PH, Vijverman V, De Cordt A, Duquet W. The clinical examination of neck pain patients: the validity of a group of tests. Manual Therapy 2007;12(1):50e5. de Koning CH, van den Heuvel SP, Staal JB, Smits-Engelsman BC, Hendriks EJ. Clinimetric evaluation of active range of motion measures in patients with nonspecific neck pain: a systematic review. European Spine Journal 2008;17(7): 905e21. Dumas JP, Arsenault AB, Boudreau G, Magnoux E, Lepage Y, Bellavance A, et al. Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset. Cephalalgia 2001;21(9):884e93. Grimmer KA. Measuring the endurance capacity of the cervical short flexor endurance group. Australian Journal of Physiotherapy 1994;40:251e4. Hall T, Robinson K. The flexion-rotation test and active cervical mobility e a comparative measurement study in cervicogenic headache. Manual Therapy 2004;9(4):197e202. Huijbregts PA. Clinical reasoning in the diagnosis: history taking in patients with headache. In: Fernandez-de-Las-Penas C, Arendt-Nielsen L, Gerwin RD, editors. Tension-type and cervicogenic headache. Pathophysiology, diagnosis and management. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2010. p. 133e51. Hunder GG, Bloch DA, Michel BA, Stevens MB, Arend WP, Calabrese LH, et al. The American college of rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis & Rheumatism 1990;33(8):1122e8. International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia 2004;24(Suppl. 1):9e160 Joubert J. Migraine. Diagnosis and treatment. Australian Family Physician 2005; 34(8):627e32. Kale N, Eggenberger E. Diagnosis and management of giant cell arteritis: a review. Current Opinion in Ophthalmology 2010;21(6):417e22. Obermann M, Katsarava Z. Epidemiology of unilateral headaches. Expert Review of Neurotherapeutics 2008;8(9):1313e20. Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Manual Therapy 2007;12(3):256e62. Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001;21: 107e9. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The cervicogenic headache international study group. Headache 1998;38(6): 442e5. Sjaastad O, Bakketeig LS. The rare, unilateral headaches. Vaga study of headache epidemiology. Journal of Headache and Pain 2007;8(1):19e27. Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: Vaga study of headache epidemiology. Acta Neurologica Scandinavica 2008;117(3): 173e80. Smetana GW, Shmerling RH. Does this patient have temporal arteritis? Journal of the American Medical Association 2002;287(1):92e101. Uthaikhup S, Sterling M, Jull G. Cervical musculoskeletal impairment is common in elders with headache. Manual Therapy 2009;14(6):636e41. van Suijlekom JA, de Vet HC, van den Berg SG, Weber WE. Interobserver reliability of diagnostic criteria for cervicogenic headache. Cephalalgia 1999; 19(9):817e23. Vincent M. Validation of criteria for cervicogenic headache. Functional Neurology 1998;13(1):74e5. Yi X, Cook AJ, Hamill-Ruth RJ, Rowlingson JC. Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? Journal of Pain 2005;6(10):700e3.
Contents lists available at SciVerse ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Diagnostic work-up of an elderly patient with unilateral head and neck pain. A case report Willem De Hertogh a, c, *, Peter Vaes c, d, Jan Versijpt b a Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, D.S.121, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgium b Neurology Department, University Hospital Brussels, Brussels, Belgium c Department of Physiotherapy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium d Department of Manual Therapy, Faculty of Medicine and Pharmacology, Vrije Universiteit Brussel, Brussels, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 May 2012 Received in revised form 9 August 2012 Accepted 31 August 2012
Headache patients frequently contact physiotherapists and manual therapists. In case of elderly patients with unilateral headache, neck and facial pain clinical practice guidelines recommend further referral for medical investigation to exclude red flags. The present patient was seen in a multidisciplinary headache clinic. He was referred by the neurologist (headache specialist) for physiotherapeutic assessment after screening for red flags, including giant cell arteritis (GCA). After first assessment, GCA was considered unlikely, since the sedimentation rate, as a marker for inflammation, was only slightly elevated. The purpose of the referral was to exclude cervicogenic headache (CEH) and to explore physical treatment as a therapeutic option. Physiotherapeutic assessment consisted of a history taking on CEH signs (Sjaastad criteria, 1998), followed by cervical spine assessment including tests for neck mobility, joint pain, and endurance of the short neck flexors. The patient’s history revealed no specific signs of CEH and cervical spine assessment was negative. In consultation with the neurologist, the diagnosis of CEH was abandoned. Since palpation of the temporal artery proved to be painful, laboratory examination and biopsy of the temporal artery were thereafter performed, this time revealing GCA. Appropriate treatment (high dose steroids) was initiated promptly, with a good clinical evolution. The presented case shows the potential of a multidisciplinary collaboration in the clinical diagnostic work-up of patients with head and neck pain. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Headache Diagnosis Physiotherapeutic assessment Red flag
1. Introduction Unilateral headaches can be a challenging diagnostic issue. The most common unilateral headache is migraine. It occurs in approximately 10% of the population (year-prevalence). Reports of the prevalence of cervicogenic headache (CEH) vary widely ranging from 2.2 up to 4.1% (Sjaastad and Bakketeig, 2008; Antonaci and Sjaastad, 2011). Other strictly unilateral headache types like trigeminal autonomic cephalalgias (e.g. cluster headache) are very rare (Sjaastad and Bakketeig, 2007; Obermann and Katsarava, 2008). Although distinct characteristics can be identified, unilateral headaches can be challenging due to the overlap of diagnostic criteria where, moreover, misdiagnosis can lead to delayed appropriate
* Corresponding author. Department of Physiotherapy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium. E-mail address: [email protected] (W. De Hertogh). 1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2012.08.008
treatment (Yi et al., 2005). This clinical overlap can be explained by a common pathophysiological pathway. Indeed, convergence of input from the trigeminal nerve and from the upper cervical spine occurs in the caudal part of the spinal trigeminal nucleus. This convergence can lead to referred pain in the head from an upper cervical nociceptive source (Piovesan et al., 2001). The opposite is equally true: an intracranial nociceptive source can give rise to referred cervical pain (Bartsch and Goadsby, 2003). According to clinical guidelines, specialist referral for further assessment is recommended when red flags are suspected. A new headache in patients aged over 50 is considered a red flag where giant cell arteritis (GCA) needs to be ruled out. This case report describes a patient who was seen by a neurologist (headache specialist), who referred the patient for physiotherapy assessment. The intention is to illustrate the clinical diagnostic process of an elderly patient with unilateral head and neck pain and illustrate the potential value of a multidisciplinary collaboration.
W. De Hertogh et al. / Manual Therapy 18 (2013) 598e601
599
lacrimation and redness of the eye next to rhinorrhea were slightly present. Previous treatment was purely symptomatic and consisted of paracetamol for pain relief. Medical history revealed polyarthrosis, sinus surgery, depression, obesity and arterial hypertension. Given the unclear etiology in a patient with both head and neck pain, the patient was referred to the multidisciplinary evaluation where patients are assessed by both the neurologist and physiotherapist. 2.1. Assessment by the neurologist
Fig. 1. Body chart indicating the location of the patients complaints (lateral view).
2. Case description A 62-year old man consulted a headache specialist because of a strictly left-sided neck pain, headache and facial pain (See Figs. 1 and 2 ). This unremitting pain had been present for two months. The pain was perceived as located in the left suboccipital and neck region, radiating to the ipsilateral head and facial region. No specific moment of onset could be specified neither could a specific trigger be identified. It was a continuous pain, which seemed to increase when lying down. Routine physical activity appeared to diminish headache intensity. Accompanying symptoms such as nausea, vomiting, photo- and phonophobia were all absent. Ipsilateral
Unilateral head and neck pain can be present in various headache types, including migraine without aura, trigeminal autonomic cephalalgias (in this case in particular hemicrania continua since we are dealing with an unremitting headache), and CEH. Consequently, these were listed as working diagnoses. The diagnostic criteria of the International Headache Society (IHS) for migraine and hemicrania continua are applied and listed in Table 1 (International Headache Society, 2004). Caution is required in patients above 50 years of age complaining of a new headache. This might potentially be a GCA or temporal arteritis. When misjudged, it can lead to permanent visual loss or other neurologic or systemic complications. An overview of red flags in headache patients is listed in Table 2. Laboratory tests were performed, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) next to imaging such as ultrasound of the temporal arteries (Kale and Eggenberger, 2010). The ESR is a highly sensitive test, and is the most useful to rule out GCA (Smetana and Shmerling, 2002). Laboratory tests revealed an ESR of 44 mm/h (max 30 mm/h) and a CRP of 44.8 mg/L (max 5 mg/L). These values indicate a mild inflammatory state, but ESR remained below the threshold of 50 mm/h, as defined by the American College of Rheumatology (Hunder et al., 1990). Consequently, temporal arteritis was not withheld at this stage and a further work-up was performed. The patient’s headache was unilateral, but was not aggravated by routine physical activity, and no associated symptoms like photo- or phonophobia were present. Also, the headache had a rather constant character. Consequently, the diagnosis of migraine was considered less likely (yielding only ‘probable migraine’ according to the IHS criteria).
Fig. 2. Body chart indicating the location of the patients complaints (frontal and dorsal view).
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W. De Hertogh et al. / Manual Therapy 18 (2013) 598e601 Table 1 Diagnostic criteria of migraine without aura and hemicrania continua (International Headache Society, 2004). Migraine without aura
Hemicrania continua
Headache presents in attacks, lasting 4e72 h if untreated or unsuccessfully treated Headache has at least two of the following characteristics: unilateral location pulsating quality moderate or severe pain intensity aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs) During an attack at least one of the following: nausea and/or vomiting photophobia and phonophobia
Continuous headache, without pain-free periods
Not attributed to another disorder
Trigeminal Autonomic Cephalalgias (TAC) form a group of mostly strictly unilateral headache types of which the best known is cluster headache characterized by excruciating headache associated with at least one autonomic feature like restlessness, ipsilateral lacrimation, conjunctival injection, nose obstruction or rhinorrhea. Hemicrania continua is the only member of this group where patients have unremitting headache. Since hemicrania continua is strictly responsive to indomethacin, this was prescribed for the patient. The patient took it up to a dose of 150 mg but it appeared to be ineffective so consequently, the diagnosis of hemicrania continua was abandoned. 2.2. Physiotherapeutic assessment This consisted of a history taking focusing on CEH characteristics as described by Sjaastad et al. (1998) (see Table 3). These criteria have good clinimetric properties (Vincent, 1998; van Suijlekom et al., 1999; Antonaci et al., 2001; Huijbregts, 2010) and are more frequently used than the IHS criteria (Huijbregts, 2010). The patient described his headache as a sidelocked unilateral headache, primarily located occipitally, starting in the neck. He perceived his cervical mobility as limited. No ipsilateral shoulder or arm pain was reported. No mechanical headache triggers such as maintained postures or repeated movements were identified. In addition to the history taking, a cervical spine assessment was performed. It included an assessment of the cervical range of motion, joint pain on palpation and endurance of the short neck flexors. Cervical range of motion was assessed actively for flexion/ extension, rotation and side bending. Passive tests rating pain provocation (recognizable headache) and mobility were performed Table 2 Clinical signs indicative of possible underlying pathology (red flags) Adapted from Huijbregts (2010) and Joubert (2005). Clinical sign
Suspected underlying pathology
New headache in patients over 50 years of age
Giant cell arteritis/brain tumor Intracranial hemorrhage Subarachnoid hemorrhage
Headache onset after trauma Severe headache of sudden onset (thunderclap headache or first and worst headache) Persistent and/or progressive headache Headache associated with illness, fever and neck stiffness Focal signs or symptoms Headache triggered by changes in posture
Brain tumor Meningitis Stroke Cerebrospinal fluid dysfunction
Headache has all of the following characteristics: unilateral pain without side-shift daily and continuous, without pain-free periods moderate intensity, but with exacerbations of severe pain
At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: conjunctival injection and/or lacrimation nasal congestion and/or rhinorrhea ptosis and/or miosis Complete response to therapeutic doses of indomethacin Not attributed to another disorder
(De Hertogh et al., 2007). In addition the flexion-rotation test (Hall and Robinson, 2004; Ogince et al., 2007) was performed, given its high diagnostic value for CEH. Since cervical spine dysfunctions are common and not headache-specific in elders (Uthaikhup et al., 2009), an additional advantage of assessing rotation is that it allows to make lefteright comparisons. The muscle endurance of the short neck flexors was assessed as first described by Grimmer (Grimmer, 1994). This test has shown to have good clinimetric properties (de Koning et al., 2008). It has been used in previous studies addressing physical impairments in CEH (Dumas et al., 2001) and in recent clinical trials dealing with headache treatment (Castien et al., 2011). Cervical mobility appeared to be limited, but this was considered as normal for his age. No lefteright differences during the rotations could be observed. Joint palpation revealed no relevant pain provocation (i.e. no provocation of the recognizable headache). The Table 3 Criteria for cervicogenic headache (Sjaastad et al., 1998). Major criteria of cervicogenic headache Symptoms and signs of neck involvement: (a) precipitation of head pain, similar to the usually occurring one: (1) by neck movement and/or sustained awkward head positioning, and/or: (2) by external pressure over the upper cervical or occipital region on the symptomatic side (b) restriction of the range of motion (ROM) in the neck (c) ipsilateral neck, shoulder, or arm pain of a rather vague nonradicular nature or, occasionally, arm pain of a radicular nature. Confirmatory evidence by diagnostic anesthetic blockades Unilaterality of the head pain, without side-shift Head pain characteristics - moderate-severe, nonthrobbing, and non-lancinating pain, usually starting in the neck - episodes of varying duration, or fluctuating, continuous pain Other characteristics of some importance - only marginal effect or lack of effect of indomethacin - only marginal effect or lack of effect of ergotamine and sumatriptan - female sex - not infrequent occurrence of head or indirect neck trauma by history, usually of more than only medium severity. Lesser importance Various attack-related phenomena, only occasionally present, and/or moderately expressed when present: - nausea - phonophobia and photophobia - dizziness - ipsilateral “blurred vision” - difficulties on swallowing - ipsilateral edema, mostly in the periocular area
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muscle endurance of the short neck flexors was not impaired (patient was able to maintain the flexed and chin-tucked position for 40 s). The lack of positive findings in history taking and physical examination made CEH an unlikely diagnosis, which was discussed with the neurologist. 2.3. Additional assessment by the neurologist Palpation of the temporal artery revealed tenderness over the left but also less pronounced over the right temporal artery. This clinical sign is indicative for giant cell arthritis, and appropriate additional tests were scheduled. The laboratory examination this time showed an ESR of 66 mm/h, CRP-value was 58.3 mg/L. Both are indicative of an inflammatory process and a biopsy of the temporal artery was scheduled which confirmed the diagnosis of GCA. Steroids (methylprednisolon at an initial dose of 64 mg) were promptly initiated achieving a swift recovery with good response to the headache. Steroids were continued and slowly tapered over the following months. The patient’s condition remained well until the last follow-up (nearly one year after diagnosis). 3. Discussion The present case report describes an elderly patient with unilateral headache, facial and neck pain. This combination of symptoms is frequently encountered by physiotherapists. The aim of the present case description was manifold. First, the purpose was to illustrate that unilateral headache and neck pain occurs in various headache types and is not limited to CEH. Also, overlap between headache types can occur. This was also documented by Yi et al. (2005) who found cervicogenic factors in previously diagnosed migraine patients. The second purpose was to elaborate on the diagnostic criteria of relevant unilateral headache types, and to mention the diagnostic criteria of migraine, hemicrania continua, CEH and temporal arteritis. In various countries, patients have direct access to physiotherapy. Hence, it is mandatory that physiotherapists recognize relevant headache types and select those they can treat and distinguish them from those which need further referral to a physician. The presented case was referred by a neurologist, after screening for red flags. Hence, the third aim was to illustrate that caution for serious underlying pathologies always remains necessary. In case of negative findings from a physiotherapeutic assessment, consultation of the referring doctor is recommended. Fourth, the additional value of a physiotherapeutic assessment in the clinical diagnostic process of headache patients was illustrated. Clinicians are biased by their professional background. The multidisciplinary approach contributed here to the early abandonment of CEH in the list of potential diagnoses. No classic additional CEH tests such as diagnostic blocks were scheduled. This probably has shortened the time to diagnosis. Since time is an important factor in the case of GCA with its known potential major complications like permanent vision loss and neurovascular complications, this was a clinically relevant contribution. 4. Conclusion Headache and neck pain are frequently encountered by physiotherapists, and is not restricted to the diagnosis of CEH. Especially in countries with direct access to physical treatment, knowledge of red flags is mandatory. Caution remains necessary even after screening of the patient by a physician, since medical conditions
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can evolve. Physiotherapists can as such substantially contribute to the clinical diagnostic work-up of headache patients. Acknowledgments Willem De Hertogh is partially supported by a research grant from the UZ Brussel Willy Gepts Fund 2009. References Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia 2001;21(5):573e83. Antonaci F, Sjaastad O. Cervicogenic headache: a real headache. Current Neurology and Neuroscience Reports 2011;11(2):149e55. Bartsch T, Goadsby PJ. Increased responses in trigeminocervical nociceptive neurons to cervical input after stimulation of the dura mater. Brain 2003;126(Pt 8): 1801e13. Castien RF, van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia 2011;31(2):133e43. De Hertogh WJ, Vaes PH, Vijverman V, De Cordt A, Duquet W. The clinical examination of neck pain patients: the validity of a group of tests. Manual Therapy 2007;12(1):50e5. de Koning CH, van den Heuvel SP, Staal JB, Smits-Engelsman BC, Hendriks EJ. Clinimetric evaluation of active range of motion measures in patients with nonspecific neck pain: a systematic review. European Spine Journal 2008;17(7): 905e21. Dumas JP, Arsenault AB, Boudreau G, Magnoux E, Lepage Y, Bellavance A, et al. Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset. Cephalalgia 2001;21(9):884e93. Grimmer KA. Measuring the endurance capacity of the cervical short flexor endurance group. Australian Journal of Physiotherapy 1994;40:251e4. Hall T, Robinson K. The flexion-rotation test and active cervical mobility e a comparative measurement study in cervicogenic headache. Manual Therapy 2004;9(4):197e202. Huijbregts PA. Clinical reasoning in the diagnosis: history taking in patients with headache. In: Fernandez-de-Las-Penas C, Arendt-Nielsen L, Gerwin RD, editors. Tension-type and cervicogenic headache. Pathophysiology, diagnosis and management. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2010. p. 133e51. Hunder GG, Bloch DA, Michel BA, Stevens MB, Arend WP, Calabrese LH, et al. The American college of rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis & Rheumatism 1990;33(8):1122e8. International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia 2004;24(Suppl. 1):9e160 Joubert J. Migraine. Diagnosis and treatment. Australian Family Physician 2005; 34(8):627e32. Kale N, Eggenberger E. Diagnosis and management of giant cell arteritis: a review. Current Opinion in Ophthalmology 2010;21(6):417e22. Obermann M, Katsarava Z. Epidemiology of unilateral headaches. Expert Review of Neurotherapeutics 2008;8(9):1313e20. Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Manual Therapy 2007;12(3):256e62. Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001;21: 107e9. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The cervicogenic headache international study group. Headache 1998;38(6): 442e5. Sjaastad O, Bakketeig LS. The rare, unilateral headaches. Vaga study of headache epidemiology. Journal of Headache and Pain 2007;8(1):19e27. Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: Vaga study of headache epidemiology. Acta Neurologica Scandinavica 2008;117(3): 173e80. Smetana GW, Shmerling RH. Does this patient have temporal arteritis? Journal of the American Medical Association 2002;287(1):92e101. Uthaikhup S, Sterling M, Jull G. Cervical musculoskeletal impairment is common in elders with headache. Manual Therapy 2009;14(6):636e41. van Suijlekom JA, de Vet HC, van den Berg SG, Weber WE. Interobserver reliability of diagnostic criteria for cervicogenic headache. Cephalalgia 1999; 19(9):817e23. Vincent M. Validation of criteria for cervicogenic headache. Functional Neurology 1998;13(1):74e5. Yi X, Cook AJ, Hamill-Ruth RJ, Rowlingson JC. Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? Journal of Pain 2005;6(10):700e3.