Managing Adult Headache Disorders

Diagnosis and Treatment Decision Assister

This assister is based on a published Clinical Practice Guideline. See About this decision assister. Clinical Practice Guidelines contain evidence-based recommendations based on best available evidence at the time of publication. 

Healthcare professionals are encouraged to review recent high-quality studies to further guide clinical decisions where appropriate.


History and Examination

Take your patient's history and conduct their physical examination:

  • Ask probing questions to understand key features of patient history and symptoms to help differentiate headache types using the IHS classification.
  • Ask about potential acute or preventive medications your patient routinely uses for their headache pain.
  • Identify "red flag" symptoms that would reflect a problem within the head or neck and alert you to a more serious cause of headache:
    • Positive findings with SNOOP.
    • Neck or occipital pain with a sharp quality and severe and persistent headache.
    • Seizures.
  • Identify risk factors for cervical artery dissection (CAD).
  • Consider using existing tools to facilitate headache diagnosis, to assess headache impact and headache-related disability, and to track treatment outcomes:
  • Perform a thorough physical exam to help differentiate headache types by IHS classification
  • Perform or request laboratory tests and diagnostic imaging as indicated.
  • If your patient presents with symptoms of more than one type of headache, diagnose them separately and manage them appropriately.

To determine the recommended care for your patient, answer the questions as they appear:

Is there a potentially serious cause of headache?

 

SNOOP

The mnemonic SNOOP has been developed by researchers in other primary healthcare settings as a reminder of the red flags that may point to the potential of a more serious, secondary headache:

  • S-Systemic signs or symptoms: fever, weight loss, history of malignancy or human immunodeficiency virus (HIV), or meningitis.
  • N-Neurologic signs or symptoms: hemiparesis, hemisensory loss, diplopia, or dysarthria.
  • O-Onset: "Worst headache of my life," headache that reaches peak intensity within seconds to minutes (thunderclap headache).
  • O-Older age: new onset headache over 40 years of age.
  • P-Progression of existing headache disorder: change in the quality, location, or frequency of existing headaches.

Adapted from: Martin V.T. Simplifying the diagnosis of migraine headache. Adv Stud Med. 2002; (4):200-207.

Risk Factors for CAD

CAD is one potential cause of secondary headache. Risk factors for CAD in patients under the age of 45:

  • Smoking
  • Use of oral contraceptives

Recent research suggests that migraine with aura may be a risk factor for CAD whereas migraine without aura is not. Further research is needed to develop a full understanding of the balance between benefits and risks for patients with headaches.

Recommendation

This is a clinical emergency: immediate referral is indicated.

Classify Headache

Is the headache possibly caused by underlying problems in the neck or head?



 

Secondary Headache

Match the symptoms and signs below to diagnose cervicogenic headache.

Note: Only cervicogenic headache is included here because it is the only secondary headache type with clinically significant research evidence upon which to comment for this CPG. Consult the International Classification of Headache Disorders 2nd edition (ICHD-2) for complete diagnostic information.

Warning: cervical artery dissection (CAD) is a potential cause of secondary headache.

Cervicogenic Headache

Signs and Symptoms


Cervicogenic headache
  • Pain referred from a source in the neck and perceived in one or more regions of the head, face, or both.
  • Clinical, laboratory, and imaging evidence (performed as indicated) of a disorder within the cervical spine or soft tissues of the neck known to cause headache.
  • Clinical signs that implicate a source of pain in the neck: mechanical exacerbation of pain, reduced cervical range of motion, focal neck tenderness, and trigger points that refer to the head.
  • When myofascial tender spots are the only cause, the headache should be diagnosed as tension-type headache, not cervicogenic headache.
Continue to treatment?

Risk Factors for CAD

CAD is one potential cause of secondary headache. Risk factors for CAD in patients under the age of 45:

  • Smoking
  • Use of oral contraceptives

Recent research suggests that migraine with aura may be a risk factor for CAD whereas migraine without aura is not. Further research is needed to develop a full understanding of the balance between benefits and risks for patients with headaches.

Cervicogenic Headache Treatment

Note: The selection, frequency, dosage, and duration of treatment(s) will depend on the nature of the headaches, and your clinical judgment and knowledge of the patient's best interest.

Recommended Treatment

  • Joint manipulation or mobilization:*
    • Spinal manipulation twice weekly for 3 weeks.
    • Maitland joint mobilization eight to twelve times over 6 weeks.
  • Deep neck flexor exercises twice daily over 6 weeks. There is no consistently additive benefit of combining deep neck flexor exercises and joint mobilization for cervicogenic headache.

*Choose low and high velocity techniques based on initial and progressive assessments of patient's cervical joint dysfunction.

If appropriate, consider co-management, referral, or both.

Is treatment providing clinically significant improvement?

 

Primary Headache

Match the symptoms and signs below to diagnose migraine or tension-type headache.

Note: Only migraine and tension-type headaches are included here because they are only primary headache types with clinically significant research evidence upon which to comment for this CPG. Consult the International Classification of Headache Disorders 2nd edition (ICHD-2) for complete diagnostic information.

Migraine Headache

Signs and Symptoms


Migraine headache
  • Headache not likely caused by underlying problems in the neck or head.
  • Recurrent.
  • 4-72 hour duration.
  • Unilateral pain.
  • Pulsatile pain.
  • Moderate or severe intensity.
  • Aggravated by routine activities.
  • During headache, one or more of the following are present:
    • Nausea
    • Vomiting
    • Photophobia
    • Phonophobia

Headache Subtype

Fifteen or more headaches per month for over 3 months: chronic migraine headaches with or without aura; otherwise, episodic migraine headaches with or without aura.

Tension-Type Headache

Signs and Symptoms


Tension-type headache
  • Headache not likely caused by underlying problems in the neck or head.
  • Frequent episodes.
  • Lasts minutes to days.
  • Bilateral pain, pressing, tightening (band-like).
  • Mild to moderate intensity.
  • No nausea or vomiting.
  • Either photophobia or phonophobia.
  • Not aggravated by routine activities.
  • May or may not be associated with pericranial tenderness on manual palpation.

Headache Subtype

Fifteen or more headaches per month for over 6 months: chronic tension-type headaches; otherwise, episodic.

What type of headache is it (continue to treatment)?

 

Migraine Headache Treatment

Note: The selection, frequency, dosage, and duration of treatment(s) will depend on the nature of the headaches, and your clinical judgment and knowledge of the patient's best interest.

Recommended Treatment

  • Spinal manipulation one to two times weekly for 8 weeks.
  • Weekly 45-minute massage with focus on neuromuscular and trigger point framework of back, shoulder, neck, and head for episodic migraine.
  • Multimodal and multidisciplinary care: group exercise, relaxation, stress, and nutritional counseling.

If appropriate, consider co-management, referral, or both.

Is treatment providing clinically significant improvement?

 

Tension-Type Headache Treatment

Note: The selection, frequency, dosage, and duration of treatment(s) will depend on the nature of the headaches, and your clinical judgment and knowledge of the patient's best interest.

Recommended Treatment

Low-load craniocervical mobilization, for example, Resistance Exercise Systems or TheraBand®:

  • 10 minutes twice daily for the first 6 weeks.
  • At least twice weekly for 6 months afterward.

If appropriate, consider co-management, referral, or both.

Is treatment providing clinically significant improvement?

 

Significant Improvement

Reassess and do the following as indicated:

  • Continue your current headache treatment.
  • Transition your patient to supportive care.
  • Transition your patient to elective care.
  • Release your patient from care.

No Significant Improvement

  • Mirror your initial history and physical examination.
  • Modify your current headache treatment or refer as indicated.


About this Decision Assister

This decision assister was created by Vic Weatherall, DC (technical writer and e-learning developer): initial release July 26, 2013; last modification date June 22, 2014. It is based on the Clinical Practice Guideline for the Management of Headache Disorders in Adults—Practitioner's Guide(1) of the Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache.(2)

The clinical practice guideline (CPG) is credited to the following people on behalf of the Canadian Chiropractic Association (CCA) and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (Federation) Clinical Practice Guidelines Project:

  1. Bryans R, Decina P, Descarreaux M, Duranleau M, et al. Clinical Practice Guideline for the Management of Headache Disorders in Adults. Canadian Chiropractic Association (CCA) and Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (Federation) Clinical Practice Guidelines Project. 2011 Jun.
  2. Bryans R, Descarreaux M, Duranleau M, et al. Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache. J Manipulative Physiol Ther. 2011 Jun;34(5):274-89.