The Headache Diagnosis and Management Series for the Chiropractor, Part V

By Darryl Curl
This is the fifth article of the series on headache diagnosis and management. Previous articles of this series may be found on the DC website.

Did you know that 35%-40% of patients who seek treatment for their headache suffer from daily or near-daily headache? Today, we will delve into the five subtypes of chronic daily headache (CDH). By the way, did you speak to your patients to see if they ever experienced CDH and what they did to resolve their predicament? Please, take the time to do so.

CDH Classification

CDH, as we have learned, consists of only five headache subtypes. This is fortunate in the differential diagnosis for sufferers of daily or near-daily headache, because the limited list greatly eases the burden of diagnosis and management for the chiropractor.

The five subtypes of CDH are:

  1. chronic tension-type headache (CTTH);
  2. CTTH-migraine complex;
  3. new persistent daily headache;
  4. post-head trauma headache; and
  5. cervicogenic headache.

Quick Reference to Key Features

CTTH Features

• pressing, tightening;
• usually mild to moderate in severity;
• may inhibit (but not prohibit) ADLs;
• bilateral, may have pericranial or cervical tenderness;
• not aggravated by physical activity;
• no vomiting; and
• may have nausea, photophobia or phonophobia.

CTTH-Migraine Complex That Is Transformed from Migraine

• may not retain migrainous features;
• some days there are migraine features or TTH features;
• migraine attacks interspersed with periods of TTH;
• females show definite exacerbation perimenstrually; and
• may develop suddenly or gradually.

CTTH-Migraine Complex That Is Transformed from TTH

• an uncommon type of headache (seen in only 3% to 15% of cases);
• migrainous features are infrequent;
• no significant history of migraine; and
• CTTH-migraine complex may develop suddenly or gradually.

The causes for the two rates of onset for the CTTH-migraine complex are described below.

CTTH-Migraine Complex (sudden onset) Causes

• recent trauma to head and neck;
• recent flu-like illness;
• recent aseptic meningitis;
• recent surgery;
• recent myelography; or
• recent medical illness

CTTH-Migraine Complex (gradual onset) Causes

• history of analgesic or ergotamine overuse;
• abnormal personality profile (depression);
• stress (home, work, family life) - the most common stress is a traumatic life event;
• history of hypertension treatment;
• chronic use of nonheadache medications, including sex hormones;
• in 20% of cases, no identifiable factor.

New Persistent Daily Headache

• no history of migraine, cervicogenic headache or tension-type headache;
• requires a "new headache" workup and often a neurological referral.

Post-Head Trauma Headache

• variable history of migraine, cervicogenic headache or tension-type headache;
• requires a "new headache" workup and often a referral to a neurologist.

Cervicogenic Headache (CGH)

• has been accepted by the International Association for the Study of Pain;
• not a disease, but a reaction pattern.
• best viewed as a final common pathway for several pain-generating disorders in the neck; • may be unilateral or bilateral;
• preponderance in females;
• iatrogenic precipitation is confirmatory.
• fulfills major criteria;
• head pain characteristics and other characteristics/features are not obligatory.

There is much more to say about cervicogenic headache. Next time, we will delve further into CGH and its specific diagnostic criteria.


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