The Differential Diagnosis of Head Pain and Treatment Protocols for five classifications

by Bruce Gundersen, DC,FACO

I have discovered a variety of classifications of headache, each of which seem to have some sensibility but there has been no standardization and certainly no canonization of them at this point. For the benefit of the chiropractic orthopedist who must have good background not only in what is at the forefront but also what else is out there, I have included three popular listings of classifications as follows:

  • Classification by the American Medical Association 1962
    I. Vascular--nonrecurrent
    A. Systemic infections--intense vascular headaches occur with pneumonia, tonsillitis, septicemia, typhoid fever, tularemia, influenza, measles, mumps, poliomyelitis, mononucleosis, malaria, trichinosis, and typhus.
    B. Miscellaneous Toxicity---carbon monoxide, lead, benzene, carbon tetrachloride, insecticides, and nitrites. Drugs--nitrates, indomethacin, oral progestation medications, and oral vasodilators. Drug withdrawal - ergot, caffeine, amphetamines, and many phenothiazines. Other---hypoxic states (e.g. anemia), hypercapnia, hangover (eg, hypertension), acute pressure reactions (e.g. pheochromocytoma, paraplegia), foreign protein reactions, cimulatory insufficiency of the brain, and postconvulsion.
    II. Vascular--recurrent
    A. Classic migraine
    B. Common migraine
    C. Cluster headache
    D. Hemiplegic and ophthalmoplegic migraine
    E. Lower-half headache
    III. Muscle contraction headache
    IV. Combined headache (vascular and muscle contraction)
    V. Direct or referred pain from noxious stimulation of cervical structures (periosteum, nerve roots, joints, discs, ligaments, muscles)
    VI. Cranial neuralgias
    VII. Cranial neuritides
    VIII. Traction headaches
    IX. Aural structures (referred)
    X. Nasal and sinus structures (referred)
    XI. Ocular structures (referred)
    XII. Dental structures (referred)
    XIII. Headache of delusion, conversion, or hypochondriac states
    XIV. Headache due to overt cranial inflammation
    XV. Headache of nasal vasomotor reactions
  • International Headache Society
    1. Migraine
    2. Tension-type headache
    3. Cluster headache and chronic paroxysmal hemicrania
    4. Miscellaneous headaches unassociated with structural lesion
    5. Headache associated with head trauma
    6. Headache associated with vascular disorders
    7. Headache associated with nonvascular intracranial disorder
    8. Headache associated with substances or their withdrawal
    9. Headache associated with noncephalic infection
    10. Headache associated with metabolic disorder
    11. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial~ structures
    12. Cranial neuralgias, nerve trunk pain, and deafferentation pain
    13. Headache not classifiable
  • Clinical Classifications of Headache
    1. Migraine: headache with generalized, sometimes varying autonomic disturbances
    2. Cluster---headache with circumscribed autonomic involvement
    3. Chronic headache---frequent headache with minimal or no autonomic involvement
    4. Mixed headache syndrome---combinations of chronic and migraine headaches
    5. Neuralgic headache pain--cervical or cranial nerve neuralgia
    6. Headache associated with vascular disorders
    7. Headache associated with intracranial nonvascular disorders
    8. Referred pain from aural, nasal, sinus, ocular, or dental structures
    9. Headache associated with a metabolic disorder
    10. Headache associated with local or systemic (noncephalic) infection
    11. Headache associated with substances and their withdrawal
    12. Miscellaneous headache unassociated with overt organic pathology
    13. Headache not otherwise classified

For this experience and remaining relevant to the clinical practice for the majority of chiropractic orthopedists, I have chosen to develop discourses for the following five classifications:

  • Cluster Headache Protocol
  • Hypertensive Headache
  • Migraine Headache
  • Sinus Headache
  • Cervicogenic Headache

Definition & Etiology Cluster Headache - Acute onset, abrupt, short lived unilateral head pain usually with one to three attacks. Pain is typically periorbital, frequent with occasional recurrence, usually daily with a 4 to 8 week course that often repeats itself anywhere from 3 to 18 months later. Increased incidence among middle aged men. No family history and no relevance to organic disease. Attacks may be brought on by stress, allergies, glare, nitroglycerin use, or the ingestion of specific foods. These agents may be related to a vascular component or serotonergic mechanism. Blood flow increases and cerebral blood vessels dilate during an attack.

Signs and Symptoms -The location of the symptoms is usually a sudden unilateral periorbital pain usually associated with ipsilateral nasal congestion. May affect orbital, supraorbital, and temporal regions. The quality of the pain is most often steady burning pain around the eye, deep and non-fluctuating pain, rarely pulsatile and often described as stabbing, agonizing steady ache, or deep burning. These may awaken the patient and typically begin at the same time each day or night. Pain usually starts abruptly and reaches maximum intensity quickly.

Global Considerations -Homer's syndrome may occur transiently during attack or remain as a residual deficit between attacks. If suspected, an evaluation for Pancoast's Tumor may be indicated. Other symptoms may include rhinorrhea and lacrimation, as well as nasal discharge or congestion, eyelid edema, and facial flushing.

Objective Findings -Check tension of masticatory and submandibular muscles. Rule out temporomandibular joint (TMJ) involvement. Check for hyperalgesia of skin zones in the cervical regions; trigger points of the neck and thorax; joint dysfunction of the cervicothoracic spine, acromioclavicular (AC) joint, and sternoclavicular joint and inspect for anterior weight beating, all of which would support a diagnosis of cervicogenic cephalalgia as actual primary trigger or cause of these headaches. Evaluate lung fields for apical tumor with Homer's syndrome.

Differential Diagnoses- The leading conditions from which this Cluster Headache should be differentially diagnosed are Temporal arteritis, TMJ disorder or muscles of mastication trigger points, vascular aneurysm, dental disorders, visual disturbances, brain tumor or other expansile intercranial lesion.

Treatment, Protocol and Management Goals- Initial treatment should be aimed are reduction of head pain which is most often subsequent to muscular or scleratogenous patterns. This often responds to combinations of any of the following:

  • Trigger point therapy or myofascial release.
  • Moist heat
  • High Voltage Electrical Stimulation
  • Interferrential Current Stimulation.
  • Ultrasound
  • Spray-and-stretch of the muscles referring pain
  • Manipulation of the cervical and upper thoracic spine.
  • Avoid stress and known allergic agents.
  • Avoid bright light, glare or prolonged computer screen exposure.
  • Identify and avoid known food allergens
  • Quit smoking and drinking of alcohol, coffee, teas, and colas.
  • Avoid monosodium glutamate (MSG), nitrates, aspartame, smoked meats, and dairy products.

Nutritional and Dietary Management- Specific items that have been helpful in the relief of head pain are: Baldrian, Valerian root extract, Passiflora, choline, Lithium aspartate, and Capsicum.

Patient Information Sheet- Your condition of head pain is what we call a cluster head ache. It is mostly caused by muscle tension and stress. They can come often or occur only rarely. If your headaches are not relieved by aspirin, paracetamol (acetominophen) or ibuprofen then you should see your doctor of chiropractic about them.

With headaches, as with other illnesses, obtaining the proper treatment depends on the right diagnosis. Therefore, it is important to determine whether you have migraine or another type of headache. You may have already seen a doctor about your headaches and received a medical diagnosis of migraine. If you are finding that the treatment your doctor recommended is not working, you may want to go and see your doctor again and discuss the points raised in this section.

The following symptoms and signs suggest the possibility of serious illness and warrant immediate attention: Very sudden onset of headache without warning

  • Getting a new type of headache after the age of 55
  • Headache with a fever or stiff neck
  • Headache associated with the new onset of changes in vision, weakness, sensory loss, weakness, (especially on one side of your body), or any difficulty walking
  • Headaches that progress in frequency, duration, or severity
  • Headache following an accident or head injury
  • Constant headaches that never go away

If you have any of these features, report this to the doctor. If you do not have these characteristics, but you have all three described below, you most likely have migraine:
1. You have had at least five headache attacks in your life with similar features lasting from 4 to 72 hours each.
2. You have two of the following three pain features: a) Moderate to severe pain b) Pain on just one side of the head c) Headaches that are throbbing or pulsing.
3. You have one of the following three features: a) You have aura b) You feel sick (nauseous) during your headaches c) You are usually sensitive to light and sound during your headaches

The course of treatment will be for 7 days at which time additional evaluation will be performed. If advanced imaging or laboratory work is indicated or if your progress has not reached at least 30% improvement, these procedures or a referral to another type of specialist may be indicated. As you progress, items of prevention will be discussed and your life style may be modified to include more exercise, different diet and nutritional supplements and some stress reduction.

Review of Current Literature and Research- There are several e-journals that offer information on head pain with current anecdotal articles. Here are a few:
"Struggling With Chronic Sinus & Headaches? Cayenne Pepper Nasal Spray May Be Your Savior" from Washington Man Struggles with head pain IHC:

Headache Classification System Updated by International Headache Society
Exploding Eye: Cluster Headaches Diagnosing Cluster Headache by Ninan T. Mathew, M.D. Recommended Reading 1. "Migraine Headache Disease" Diagnostic and Management Strategies - by Charles W. Theisler, Aspen Publications 1990 2. "Instant Access to Chiropractic Guidelines and Protocols" by Lew Huff and David M. Brady, Mosby 1999. Attribution Special thanks to those who have contributed to this body of knowledge: David Brady, Lew Huff, Ron Evans, Charles Theisler, Alan Korbett, Leo Bronston, References 1. Diamond S: Cluster headaches, how to distinguish from migraines, Consultant, July 1996. 2. Freemon F: Evaluation and treatment of headache, Geriatrics 33:8245, 1978. 3. Gatterman M: Chiropractic Management of spine related disorders, Baltimore, 1990, Williams & Wilkins. 4. Grabowski RJ: Current nutritional therapy, San Antonio, Tex, 1993, Image Press. 5. Hubka M, et al: A new look at the classification of headaches, Chiropr Techn (6)2, May 1994. 6. Kudrow L, Kudrow D: Inheritance of cluster headache and its possible link to migraine, Headache 34:400407, 1994. 7. Lindahl O, Lindwall L: Double blind study of a valerian preparation, Pharmacol Biochem Behav 28(4):10065-10066, 1989. 8. Marks DR, et al: A double blind placebo-controlled trial of intranasal capsaicin for cluster headache, Cephalgia 13(2):114-116, 1993. 9. Nelson C: The reliability of an instrument used to evaluate primary headaches, Proceedings of the International Conference on Spinal Manipulation, Montreal, April 30-May 'I, 1993. 10. Nimmo R: Receptor, effecters and tonus: a new approach, J Natl ChiroprAssoc, November 1957. 11. Schneider MJ: Chiropractic Management of Myofascial and muscular disorders. In Lawrence D, ed: Advances in Chiropractic, vol 3, 1996, St Louis, Mosby. 12. Solomon SS, Lipton RB, Newman LC: Prophylactic therapy of cluster headaches, Clinical Neuropharmacopea 11492:116-130, 1991. 13. Speroni E, Minghetti A: Neuro pharmacological activity of extracts from Passiflora incarnata, Planta Med 54(6):488-491, 1988. 14. Tiemey LM, McPhee SJ, Papadakis MA: Current medical diagnosis and treatment, ed 35, Appleton & Lange, 1996, Nonvalk, Conn. 15. TravellJG, Simons DG: Myofascial pain and dysfunction: the triggerpoint manual, vol 2, Baltimore, 1992, Williams & Wilkins. 16. Vernon H: The effectiveness of chiropractic manipulation in the treatment of headache: an exploration of the literature, J Manipulative Physiol Ther 18(9):611-617, 1995. 17. Werbach MR: Nutritional influences on illness, ed 2, Tarzana, Calif, 1996, Third Line Press. 18: Werbach MR, Murray. MT: Botanical influences on illness, Tarzana, Calif, 1994, Third Line Press. About The Author Bruce Gundersen graduated of National College of Chiropractic in 1977, did his orthopedics training through LACC and was certified by ABCO in 1985. He served as Vice President of ACA in 1991. He served as a postgraduate instructor for Cleveland College of Chiropractic and Texas Chiropractic College from 1986 through 1991 when he was appointed to ABCO. He served as ABCO President from 1996 to 1998. He was President of CCO from 1998 to 2001. He served as a member of the Commission on Accreditation for CCE from 1996 to 2001. He was Editor in Chief of DC Tracts from 1989 to 2000. He was instrumental in creating the "Clinical Discourses" for CCO, was chairmen of the chiropractic orthopedics syllabus committee from 2000-2002 and has written and published over 25 articles for chiropractic orthopedics.

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