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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 – T4Increased 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

Trigeminal nucleus caudalis1

Trigeminal Nucleus Caudalis

Trigeminal nucleus caudalis2

Trigeminal Nucleus Caudalis

Trigeminal nerve schema

Trigeminal Nerve: Schema

Autonomic nervous system involvement

Autonomic Nervous System Involvement

  • Parasympathetic

    • Vagus Nerve (CN X)

Vagus nerve schema

Vagus Nerve: Schema

Cranial nerve nuclei in brainstem schema

Cranial Nerve Nuclei in Brainstem: Schema

Cranial nerves schema

Cranial Nerves: Schema

Autonomic nervous system involvement1

Autonomic Nervous System Involvement

  • Sympathetic

    • T1 – T4 ascend to cervical region

Autonomic nervous system involvement2

Autonomic Nervous System Involvement

Autonomic nervous system involvement3

Autonomic Nervous System Involvement

Sympathetic nervous system

Sympathetic Nervous System

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 soft tissue cervical push pull

Treatments – Soft Tissue (Cervical) Push – Pull

Rhomboid stretch

Rhomboid Stretch

Treatments soft tissue thoracic paravertebral

Treatments - Soft Tissue (Thoracic Paravertebral)

Treatments soft tissue sns

Treatments – Soft TissueSNS

Treatments soft tissue trapezius and rhomboid stretch

Treatments – Soft TissueTrapezius and Rhomboid Stretch

Rhomboid stretch1

Rhomboid Stretch

Treatments muscle energy

Treatments Muscle Energy

  • Muscle Energy

    • Trapezius and related muscles

    • Cervical Muscles

Treatments muscle energy trapezius

Treatments Muscle Energy (Trapezius)

Treatments soft tissue cervical

Treatments – Soft TissueCervical

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 suboccipital inhibition1

Treatments Suboccipital Inhibition

Treatments suboccipital inhibition2

Treatments Suboccipital Inhibition

Suboccipital decompression

Suboccipital Decompression

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 1 st rib muscle energy1

Treatments1st Rib Muscle Energy

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.

Treatments cervical muscle energy2

TreatmentsCervical Muscle Energy

Treatments cervical muscle energy3

TreatmentsCervical Muscle Energy

Treatments cervical muscle energy4

TreatmentsCervical Muscle Energy

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