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Cephalalgia. Department of Osteopathic Manipulative Medicine University of North Texas Health Science Center Texas College of Osteopathic Medicine. Cephalalgia. Stuart Williams, DO Associate Professor Department of Osteopathic Manipulative Medicine.

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Department of Osteopathic Manipulative Medicine

University of North Texas Health Science Center

Texas College of Osteopathic Medicine



Stuart Williams, DO

Associate Professor

Department of Osteopathic Manipulative Medicine

case presentation
A 32-year-old female presents to the office with a 10 year history of headaches. The headaches often begin with a sensation of flickering lights. Later she notes a throbbing sensation, usually right or left-sided. She also describes a pressure-like, tight sensation occurring in the occipital area. Case Presentation
case presentation1
Case Presentation

When the headaches are severe, bright lights and strange smells may provoke or worsen the intensity. The patient will then prefer a dark room.

A severe headache in this patient will last several hours. She also describes a chronic, dull achy headache which has lasted several days.

  • No history of head trauma, seizure disorder, or CNS infections.
  • Family history of similar headaches in mother, and maternal grandmother.
physical examination
Physical Examination
  • WDWN female in NAD
  • Alert, oriented x 3
  • Funduscopic – sharp discs, no hemorrhages, or exudates
  • CN 2-12 intact
  • Tenderness, tightness suboccipital muscles
  • Elevated left 1st rib with surrounding spasm
  • Increased spasm in the cervical paravertebral mm. C3 – C5, RR SR
  • AA – RR
  • OA – SR RL
  • T1 – T4 Increased sympathetic tone, loss of normal kyphotic curvature, SR RL


Tension / Migraine


differential diagnosis
Differential Diagnosis
  • Migraine Headache
  • Tension Headache
  • Cluster Headache
secondary headache differential
Secondary Headache (Differential)
  • Glaucoma
  • Cerebral Aneurysm
  • Temporal Arteritis
  • Optic Neuritis
  • Carotid or Vertebral a. dissection
  • TMJ Syndrome
  • Herpes Zoster
  • Meningitis/Encephalitis
  • Sinusitis/Facial Osteomyelitis
secondary headache other causes
Secondary Headache (Other Causes)
  • Intracranial Hypertension
  • Benign Intracranial Hypertension
  • Exertional Headache (Lift, Cough, Strain)
  • Normal Pressure Hydrocephalus
  • Myofascial Pain Syndrome
  • Subarachnoid Hemorrhage
  • Subdural Hematoma
  • Viremia
secondary headache other causes1
Secondary Headache (Other Causes)
  • Stroke
  • Vasculitis
  • Cervical Spine Disorder
  • Dental Disorder
  • Anemia
  • Caffeine Withdrawal
  • Fever
  • Hypercapnea
  • Hypoxia
  • Zomig, 2.5 mg at onset of headache

Repeat x1 in 2 hours if headache is not resolved

  • Naprosyn 500 mg p.o. Bid. p.c.
mixed headache with associated cervical pain
Mixed Headache with associated Cervical Pain
  • Very common in primary care

What can be done osteopathically?

mixed headache with associated cervical pain1
Mixed Headache with associated Cervical Pain



Respiratory and Lymphatic

  • Most common headache is tension.
  • Many patients with migraine headache have coexisting tension headache.
trigeminal nucleus caudalis
Trigeminal Nucleus Caudalis
  • Major Relay Nucleus for head and neck pain.
  • Vascular Headache (Migraine)
    • Nociceptors Vascular
    • Nonnoxious Stimuli Vascular Pulsations
  • Tension Headache
    • Nociceptors Myofascial
    • Nonnoxious Stimuli Muscle Contractions
autonomic nervous system involvement
Autonomic Nervous System Involvement
  • Parasympathetic
    • Vagus Nerve (CN X)
autonomic nervous system involvement1
Autonomic Nervous System Involvement
  • Sympathetic
    • T1 – T4 ascend to cervical region
areas to treat osteopathically
Areas to Treat Osteopathically
  • Sympathetic
    • Lower Cervical
    • Upper T-Spine
    • Associated ribs and myofascial attachments
  • Parasympathetic
    • Suboccipital Region
treatments soft tissue
Treatments Soft Tissue
  • Soft Tissue
    • Cervical Spine Push-Pull
    • Thoracic Spine Trapezius, Rhomboids
treatments muscle energy
Treatments Muscle Energy
  • Muscle Energy
    • Trapezius and related muscles
    • Cervical Muscles
treatments suboccipital inhibition
Treatments Suboccipital Inhibition
  • Suboccipital Inhibition
    • Pads of fingers just beneath superior nuchal line in suboccipital soft tissue.
    • Weight of head rests on pads of fingers.
treatments 1 st rib muscle energy
Treatments 1st Rib Muscle Energy
  • 1st Rib Muscle Energy
    • Pads of thumbs on rib heads directly in front of trapezius.
    • Patient should shrug both shoulders towards ears while taking a deep breath.
    • Patient should release breath slowly while letting shoulders down.
    • Continue maintaining firm caudad pressure and follow the rib caudally through exhalation maintaining new position. (Barrier)
treatments cervical muscle energy
TreatmentsCervical Muscle Energy
  • Diagnosis of Somatic Dysfunction
    • C-Spine
    • Side-bending
    • Rotate each segment
treatments cervical muscle energy1
TreatmentsCervical Muscle Energy
  • Cervical Muscle Energy (C2 – C7)
    • Induce side-bending to restrictive barrier with pad of thumb.
    • Flex or extend neck to localize to particular segment.
    • Have patient side-bend away from barrier.
    • Side-bend patient to new restrictive barrier.