Additional Material

Suspicious Headache Features and Differential

  • Late first onset of headache could be tumor or temporal arteritis
  • Worst headache of life could be subarachnoid hemorrhage
  • Vision loss or hearing changes could be intracranial hypertension
  • Rapid peak intensity, especially with exertion could be vascular headache (bleed or clot)
  • Headache with fever could be meningitis or encephalitis
  • Headache after trauma could be hematoma
  • Headache with abnormal neurologic findings could be an abscess, neoplasm, arteritis, infection, clot arterial-venous malformation, dissection

Physical Therapy Perspective

Manual Therapy/Musculoskeletal Evaluation

Musculoskeletal Findings Associated with Headaches

Joint Tenderness with Manual Overpressure/Palpation

  • Cervical facets: restricted end-feel and local/referred pain with springing palpation
  • Temporomandibular joints: asymmetrical or restricted motion with audible/palpable crepitus
Xray of lower jaw, side of face
Xray of cervical joint

Muscle Tenderness with Palpation

  • Cervical muscles and/or muscles of mastication 
  • Trigger point “nodules”
  • “Taut bands” with twitch response
  • Elicitation of local/referred pain during palpation
Zoomed in view of muscle fibers and nodes
Muscle fibers showing taut bands and trigger point "nodules"

Dental Medicine Perspective

Temporomandibular Disorders (TMDs) and Headache

Temporomandibular disorders (TMDs) often co-exist with headaches.

  • Common subgroup of orofacial pain disorders
  • Major cause of non-dental pain in the orofacial region
  • Risk factor for primary headache disorders
  • May potentiate frequency and severity of headaches

Types of TMD Symptoms

Patients report several types of TMD symptoms.

Signs and symptoms:

  • Headaches
  • Muscle pain/fatigue ("it hurts to chew")
  • Referred toothache ("my teeth hurt")
  • Earache ("my ear aches")
  • Joint pain
  • Joint sounds/locking ("my jaw clicks and hurts," "I can't open and close")
  • Abnormal or limited jaw opening ("I can't open wide")
  • Ear sounds (tinnitus)

Factors that Predispose, Initiate or Worsen TMD

Many factors can predispose, initiate, or worsen TMD. 

  • Grinding or clenching behavior 
  • Trauma
  • Changes in occlusion
  • Systemic, genetic, psychological factors

Effective Treatment

Effective treatment simultaneously addresses all pain conditions.

Venn diagram of effective treatment for TMD, migraine headache and tension-type headache
Treatment simultaneously addressing different conditions

Instructor Guide

Overall Purpose of the Resource

The overall purpose of this educational resource is to introduce to medical and other health sciences students key principles in evaluating and managing chronic headache pain. This resource will contribute to the acquisition of important knowledge, attitudes and skills relevant to all health professionals who treat patients with chronic headaches. This  instructional module, Chronic Headaches, emphasizes the importance of considering a broad differential diagnosis that includes both primary and secondary headache types and of recognizing that multiple headache types can co‐exist in a single patient. The module also discusses psychological and behavioral factors that may contribute to the development and
progression of chronic headaches, and describes a comprehensive approach for the treatment and prevention of chronic headaches.

Potential Impact of Case Education

Improve knowledge

Increase reliance on history and physical examination skills; decrease unnecessary diagnostic testing

Change attitudes

Appreciate the value of pharmacological and non‐pharmacological management strategies in managing headaches; appreciate association between stress and headache chronicity

Gain skills

Reinforce patients’ behavioral and lifestyle modifications to reduce headache frequency; prevent the development of chronic daily headache.

Learning Objectives

The table below outlines the learning objectives of this instructional module. Objectives are categorized as being universal (i.e., relevant to health professional learners from all professions) or specific (i.e., address issues that are most likely to be encountered within a given profession). Specific objectives are further subdivided into traditional and interprofessional objectives. Traditional objectives address issues that are relevant to the learner’s interactions with and treatment of their patients specific to their profession. Interprofessional objectives introduce learners to the importance of interprofessional
communication and collaboration.

Universal Learning Objectives

  1. Recognize the presence of different headache types co‐existing in a single patient
  2. Articulate the impact of psychological stress, medication overuse, poor sleep and other factors on the development and progression of chronic headaches
  3. Describe a comprehensive approach for the treatment and prevention of chronic headaches including pharmacologic measures and behavioral modifications

Learner‐Specific Objectives

Medical/Nurse Practitioner/Dental


  • Recognize mixed migraine and tension type headaches in chronic headache patients
  • Recognize medication overuse as a contributor to chronic headaches
  • Identify depression and anxiety symptoms in headache patients


Describe the role of the pharmacist in recognizing and educating patients about analgesic overuse.



  • Include data on headache triggers and risk factors in the nurse’s communication to the provider
  • Recognize the importance of non‐pharmacologic approaches to headache management
  • Describe the nurse’s role in promoting lifestyle modifications


Describe the role of the physician in recognizing psychological distress as a contributor to the
progression of chronic headaches.



  • Recognize analgesic overuse as a common contributor to chronic headaches
  • Describe the role of preventative medications for headache
  • Describe potential risks and side effects of over‐the‐counter headache pain relievers


Describe the role of the physical therapist in providing non‐pharmacologic treatment approaches.

Physical Therapy


  • Identify findings on the physical examination associated with chronic headaches
  • Describe the importance of regular exercise and manual therapy for headache patients
  • Identify psychological distress and analgesic overuse as factors limiting the effectiveness of physical rehabilitation


Describe the nurse’s role in reinforcing lifestyle modifications.

Conceptual Background

Chronic headache is a common disorder that accounts for substantial morbidity worldwide. In 2016, the International Global Burden of Disease Study estimated that over a quarter of the world’s population (26.1%) is burdened by tension‐type headaches and 14.4% suffer from migraines (1). These numbers are not mutually exclusive, however, because patients often present with mixed migraine and tension type headaches, making diagnosis and treatment challenging. The personal and societal impact of headaches is burdensome in terms of direct health care costs, reduced productivity at work, and diminished quality of life. The Migraine Research Foundation estimates the medical cost of treating chronic migraine in the United States to be over $5 billion annually (2). Work absenteeism in migraine sufferers is substantial, accounting for 113 million lost work days per year, and costing U.S. employers more than $13 billion annually [2]. The personal impact of these headaches is also costly and demonstrated by a lower health‐related quality of life and increased risk for comorbid disorders such as
depression and anxiety [3].

Effective headache management relies on management of acute attacks and prevention strategies to reduce headache frequency. While treatment usually requires a pharmacological approach, prevention may combine medication, psychosocial, physical treatments and behavioral interventions. Even the best headache medications may have limited efficacy or intolerable side effects, and are costly [4]. Patients who rely solely on medications to treat headaches are prone to overuse them, thus increasing their risk of medication overuse (“rebound”) headaches [5]. Use of behavioral and lifestyle modification techniques to reduce common headache triggers such as stress can be extremely effective. Studies of stress and headache demonstrate that behavioral therapies either alone or in combination with pharmacotherapy improves treatment outcomes 35‐55% over baseline [6]. Regular exercise and physical therapy can also decrease headaches by reducing stress and relieving neck pain.

Practical Implementation Advice

The module is designed to optimize learning flexibility. That is, students can complete it independently over a span of 60 minutes or less. If the student wishes to delve into some of the additional linked resources, additional time will be required and can be undertaken at the student’s leisure.

The student disciplines that are targeted specifically are medical students (or nurse practitioner [NP]/physician assistant [PA] students), pharmacy students and physical therapy students.

Typically, the module should be embedded into courses in the 3rd year of the medical school curriculum (or the equivalent in other Schools of health sciences), after students have had didactic courses in physiology, pathology, and pharmacology. Working knowledge of basic pain physiology will be reviewed in the context of the module; prior exposure to such  knowledge is helpful as is an understanding the concepts in the module.

Allied health professionals will need to have had courses in anatomy and pathophysiology appropriate for their specialty in order to benefit from this learning module.

Target Audiences

  • Medical Students: Years 1‐4
  • Nursing Students: Advanced undergraduates; 1st and 2nd year master’s candidates
  • Dental Students: Year 3‐4
  • Physical Therapy Students (DPT): Year 2‐3
  • Pharmacy Students: Year 3

When implemented in an Interprofessional Education (IPE) setting, we suggest introducing the case to groups of students by providing an overview of pain physiology and the basics of Interprofessional Practice (IPP) relevant to the health professional students included.


  1. Stovner LJ, Nichols E, Steiner TJ, Abd‐Allah F, Abdelalim A, Al‐Raddadi RM, Ansha MG, Barac A, Bensenor IM, Doan LP, Edessa D. Global, regional, and national burden of migraine and tensiontype headache, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018 Nov 1;17(11):954‐76. Migraine Research Foundation.
  2. Migraine fact sheet, New York, NY: MRF; 2016.
  3. Abu Bakar N, Tanprawate S, Lambru G, Torkamani M, Jahanshahi M, Matharu M. Quality of life in primary headache disorders: A review. Cephalalgia 2016 Jan;36(1):67‐91.
  4. Lake A. Behavioral medicine for chronic headache: overview and practical tools for the practicing physician. Continuum (Minneap Minn) 2006;12(6):235‐58.
  5. Diener HC, Holle D, Solbach K, Gaul C. Medication‐overuse headache: Risk factors, pathophysiology and management. Nat Rev Neurol 2016 Oct;12(10):575.
  6. Rains JC, Penzien DB, McCrory DC, Gray RN. Behavioral headache treatment: history, review of the empirical literature, and methodological critique. Headache 2005 May;45 Suppl 2:S92‐109.
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