Osteopathic Approach to the Patient with Head Pain-CBL

Facilitator Prompt: You are on your Family Medicine rotation and asked to interview and
workup a patient. The MA gives you the following information:
CC: 36 y/o African American female with fatigue, headache, and neck pain

Have the students interview the facilitator to obtain the history.

HPI:

Onset- Headaches have been problem since her mid 20’s

Location- Starts off around the temples and forehead, but then spreads to neck and back
Duration- Increasing in frequency over the last couple of months
Characterization- Feels tight at the back of the head
Aggravating- Stress from job (recently promoted)
Alleviating- Advil with minimal relief
Associated- Difficulty sleeping (can’t find a comfortable position), feels like “mind is racing”
Radiation- Spreads down neck and into upper back
Timing- Intermittent, cannot think of any specific timing patterns
Severity- 5/10 at worst, but currently at 4/10

Medications: Advil (Ibuprofen) 400 mg q4-6h PRN

Micronor (Norethindrone) 0.35 mg/day
Albuterol PRN

Allergies: NKDA, Ragweed (rhinorrhea), no food allergies

PMH: Asthma (last attack was 4 months ago)

Whiplash injury from motor vehicle accident at age 22

PSH: Appendectomy at age 9

SH:
Diet: “Watches her diet”, tries to incorporate fruits and vegetables, avoids fried foods
Exercise: Tries to be active, swims laps 3x/week
Tobacco: Denies any tobacco use
ETOH: Glass of red wine every night
Occupation: CPA
Sexual Hx: Single. Not currently sexually active.

Family History:
Paternal history: Alive-Age 57; HTN, Type 2 diabetic
Maternal history: Alive-Age 56; Tension headaches, Osteoarthritis
Siblings:
Sister: Alive-Age 33; No medical history
Brother: Alive-Age 38; No medical history
Children: No children

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Osteopathic Approach to the Patient with Head Pain-CBL

Review of Systems:

System Positive Negative

Constitutional Fatigue Weight loss, fever, chills
HEENT Dry eyes and eyelid heaviness Visual changes, blurred vision, double
as day progresses vision, yellow sclera, hearing loss,
sneezing, congestion, sore throat
Skin Rash, itching
Cardiovascular Chest pain, pressure, discomfort,
palpitations, edema
Respiratory Occasional dry morning Shortness of breath
cough
Gastrointestinal Chronic mild constipation N/V/D, food intolerance
Genitourinary Nocturia, urgency, dysuria, abnormal
vaginal discharge
Neurological Vision changes, vertigo, syncope,
paralysis, ataxia, numbness/tingling in
extremities
Musculoskeletal Neck pain and upper back
stiffness that is worse after
sitting at desk all day
Hematologic Anemia, bleeding, bruising
Lymphatic Enlarged lymph nodes
Psychiatric Feels sad, anxiety Hallucinations, altered consciousness
Endocrine Cold/heat intolerance, sweating

Physical Exam:

Vitals: Temperature: 98.6⁰F; Pulse: 78; Respiration: 18/minute; Blood Pressure: 135/89 mmHg;
Height: 5’6”; Weight: 190 lbs

General: Patient is alert and oriented x3. Patient appears her stated age and fatigued.

Skin: No rashes, ecchymoses, or lesions noted. No erythema, pallor, or dry skin.

Eyes: PERRLA, EOMI, minor conjunctival injection is noted.

ENT: No mucosal erythema. Tonsils present but not inflamed. No swollen lymph nodes. No
deviated nasal septum noted. Tympanic membrane non-erythematous, with visible cone of light.
Oropharynx moist and pink. Uvula is midline.

MSK:
 Head: Right lateral strain, CRI of 8, right occipitomastoid compression

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Osteopathic Approach to the Patient with Head Pain-CBL

 Cervical Spine: OA E RlSr, AA Rr, C2 E RlSl, C4 F RrSr

 Rib: Right rib 1 inhaled, right ribs 3-5 exhaled
 Thoracic Spine: Thoracic inlet F RrSr, T2-4 N RrSl
 Lumbar Spine: Hypertonicity of Quadratus Lumborum m. over area of T10-L2.
 Innominates/pelvis: Anterior innominate rotation on right. Left pelvic outflare.
 Sacrum: L/R Sacral torsion.

Cardiovascular: RRR no murmurs, clicks, rubs; No peripheral edema; Nail beds and digits
appear normal with good capillary return.

Respiratory: Lungs are clear to auscultation; no wheeze/rales/rhonchi

Genitourinary: No nodules or masses noted. Last menstrual period was 3 weeks ago.

Abdomen: Normoactive bowel sounds present in all 4 quadrants. Abdomen is soft without
tenderness or masses. No hepatomegaly or splenomegaly.

Neurologic: Oriented to person, time, and place. Cranial nerves 2-12 grossly unremarkable.
DTRs of upper and lower extremities are +2/4 bilaterally. Sensation intact to light touch and
pinprick.

FACILITATOR QUESTION:
2. What are the major problems this patient has based on the history and physical?
Head/neck pain
Headache
Fatigue
Stress
Anxiety
Insomnia
Somatic dysfunction

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Osteopathic Approach to the Patient with Head Pain-CBL

FACILITATOR QUESTION:
3. What are your differential diagnoses based on this patient’s presentation? What
clinical/historical details will help to differentiate these diagnoses from one another?
Biomechanical
1. Headache
a. Cervicogenic Headache
i. Caused by a disorder of the cervical spine and its component bony, disc, and/or
soft tissue elements, usually but not invariably accompanied by neck pain.
ii. Criteria to diagnose (Need at least 2)
1. Develops with temporal relation to the onset of a cervical disorder or
appearance of lesion
2. Significantly improves with improvement in or resolution of the cervical
disorder or lesion
3. Provocative maneuver significantly reduces cervical range of motion
4. Headache is abolished following diagnostic blockade of a cervical
structure or its nerve supply
iii. Clinical Details
1. History of MVA with resultant whiplash injury
b. TMJ Dysfunction
i. Caused by disk displacement, joint osteoarthritis, joint hypermobility, and
regional myofascial pain.
ii. Pain is most common in the preauricular area of the face, masseter muscles,
and/or temporal regions.
iii. Clinical Details
1. TMJ somatic dysfunctions
c. Herniated Disc
i. The intervertebral disc is composed of a tough, ligamentous outer annulus and a
gelatinous inner nucleus pulposus. The combination of intervertebral pressure
and degeneration of the ligamentous fibers can lead to a tear in the annulus,
allowing the nucleus pulposus to prolapse through the annulus. Inflammation and
radicular symptoms may ensue if the prolapsed material presses on a nerve root.
ii. Clinical Details
1. Radiculopathy
2. Electrodiagnostic studies could detect nondegenerative radiculopathy
3. Other differentials are ruled out and patient doesn’t improve with OMT
a. MRI of C-spine might be warranted at this point
Respiratory Circulatory
1. Headache
a. Sinus Headache
i. Pressure-like or dull sensation that is usually bilateral or periorbital.
ii. Sinusitis is an uncommon cause of recurrent headaches
iii. Clinical Details

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Osteopathic Approach to the Patient with Head Pain-CBL

1. Associated with nasal obstruction/congestion, lasts for several days

b. Cranial restriction of dural venous sinuses

i. Clinical Details
1. Decreased CRI, cranial suture restriction
c. Hypertensive Encephalopathy
i. Characterized by the insidious onset of headache, nausea, and vomiting, followed
by nonlocalizing neurologic symptoms such as restlessness, confusion, and, if the
hypertension is not treated, seizures and coma.
ii. Clinical Details
1. Hypertension
2. Visual symptoms
3. Fundoscopic changes
a. Retinal hemorrhages/exudates, papilledema
4. To diagnose:
a. Ophthalmologic examination and T2 MRI
d. Valsalva-maneuver Headache
i. AKA Benign Cough Headache
ii. Clinical Details
1. Most often affects people over the age of 40
2. Sudden onset, bilateral distribution, lasts from seconds to a few minutes
3. Not associated with nausea, vomiting, photosensitivity
Neurologic
1. Headache
a. Tension Headache
i. Mild to moderate intensity headache that is bilateral, non-throbbing, and not
associated with any other features
ii. Peripheral activation or sensitization of myofascial nociceptors. The increased
nociceptive stimulation of supraspinal structures results in increased facilitation
and decreased inhibition of pain transmission at the level of the spinal dorsal
horn/trigeminal nucleus, and in increased pericranial muscle activity.
iii. Criteria for Diagnosis (>2 of the following)
1. Bilateral location
2. Non-pulsating quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity
5. Absence of nausea or vomiting
6. Either photophobia or phonophobia, but not both
b. Migraine
i. Recurrent headache disorder manifesting in attacks lasting 4-72 hours.
ii. Theory of vasodilation causing migraine is no longer valid
iii. Clinical Details
1. Unilateral, pulsating, moderate to severe intensity, feel the need to retreat
to dark, quiet room
2. Associated with nausea, vomiting, photophobia, phonophobia
c. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

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Osteopathic Approach to the Patient with Head Pain-CBL

i. CSF pressure is greater than 250

ii. Headache is the most common presenting symptom
1. Can be exacerbated with changes in posture
2. Can lead to NSAID abuse
iii. Clinical Details
1. More common in young obese women
2. Headache, visual changes, pulsatile tinnitus, neck pain, shoulder pain
3. Pain with eye movement or globe compression
4. Fundoscopic exam to look for papilledema is suggested
a. Papilledema is hallmark sign
Metabolic Energetic Immune
1. Headache
a. Hypothyroidism
i. Primary hypothyroidism
1. High serum thyroid-stimulating hormone (TSH) concentration
2. Low serum free thyroxine (T4) concentration, whereas
ii. Subclinical hypothyroidism
1. Normal free T4 concentration in the presence of an elevated TSH
concentration.
iii. Secondary (central) hypothyroidism
1. Low serum T4 concentration and a
2. Serum TSH concentration that is not appropriately elevated.
iv. Clinical Details
1. Headache caused by hypothyroidism is usually bilateral and non-
pulsatile
a. Remission after normalization of thyroid levels
2. Cough
a. Top 5 Differentials for Cough
i. Respiratory (PNA/Asthma/Allergies/URI)
ii. Post Nasal Drip
iii. GERD
iv. Medication (ACE Inhibitor)
v. Other (TB, Foreign Body, etc.)
3. Fatigue
a. Chronic Fatigue Syndrome
i. >6 months of fatigue plus post-exertional malaise, unrefreshing sleep, cognitive
impairment, and orthostatic-related symptoms
ii. Proposed causes include EBV, Retroviruses
1. True immune deficiency is not a feature of CFS
iii. Clinical Details
1. Endocrine manifestations
2. Sleep disruption
b. Anemia
i. Causes can include but are not limited to decreased erythropoiesis, increased
destruction of circulating RBCs, intravascular hemolysis, blood loss

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Osteopathic Approach to the Patient with Head Pain-CBL

ii. Symptoms can be manifested by decreased oxygen delivery to tissue or

hypovolemia
iii. Clinical Details
1. Pallor, jaundice, fatigue
2. Measure MCV, MCH, MCHC and other hematologic tests
Behavioral
1. Depression
2. Anxiety

FACILITATOR QUESTION:
4. What diagnostic testing would help to further refine your diagnoses? (Give answers after
students give lists of tests and images)
CBC:

Component Normal Result

RBC 3.6-5.0 million/mm 4.2 million/mm
WBC 4000-10000 per mm3 6500 per mm3
Platelets 100,000-400,000 382,000
Hemoglobin 12-15 g/dL 13.5 g/dL
Neutrophils 40-75% 57%
Eosinophils 0.5-6% 2%
Basophils 0-2% 1%
Monocytes 3-8% 8%
Lymphocytes 15-75% 32%
MCH 31-35 g/dL 32.5 g/dL
MCHC 33.4-35.5% 34.0%
MCV 85-100 micrometers3/cell 92 micrometers3/cell

CMP:
Component Normal Result
Serum Glucose 60-100 84
BUN 5-26 16
Creatinine 0.76-1.27 1.06
eGFR >60 >60
BUN/Creatinine Ratio 8-27 15
Sodium 135-145 141
Potassium 3.5-5.2 4.4
Chloride 97-108 101
Calcium 8.7-10.2 9.9
Protein (Total) 6.0-8.5 7.6
Albumin 3.5-5.5 4.9
Globulin 1.5-4.5 2.7
A/G Ratio 1.1-2.5 1.8
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Osteopathic Approach to the Patient with Head Pain-CBL

Bilirubin (Total) 0.0-1.2 0.6

Alkaline Phosphatase 25-150 65
AST 0-40 30
ALT 0-55 32

hCG: Negative
UA: Unremarkable, GC swab negative
C-reactive protein: Normal
Facilitator Question
5. Based on these results, has your differential changed?
FACILITATOR QUESTION:
6. What are appropriate manipulative techniques and 5 model approaches to improve
quality of life and reduce headache experiences?
(Note: Do not limit the treatment plan to the chief complaint)
What other PMH, signs, and symptoms should be addressed?
(Please use the 5 models to organize your treatment plan.)

OMT:
Head- CV4, Venous Sinus Drainage, TMJ treatments, V spread
Cervical- MFR, CS, MET, FPR, BLT, Still’s,
Thoracic- MFR, HVLA
UE- Trapezius ST/CS, Levator Scapulae MET
Other-Lymphatics, Chapman’s reflexes for head region

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Osteopathic Approach to the Patient with Head Pain-CBL