Case history presentation
Names have been changed to protect patient confidentiality.
Lucy, a 51-year-old woman, presented to the clinic with a one-year history of debilitating headaches that were affecting her almost daily. She was regularly relying on painkillers and had consulted her GP on several occasions. Following her most recent appointment, she had been referred to a neurologist for further investigation.
Lucy’s symptoms were not unusual. Her pain tended to focus around the base of her skull before travelling over her scalp towards her forehead, often accompanied by pain running down one side of her neck and into her shoulder.
Lucy also experienced migraines, but she recognised these headaches as something different. This was more of a daily grind. Occasionally she woke with a headache, but more commonly it developed as the day progressed.
Pain relief reduced her symptoms, but she was fed up with taking medication and, understandably, increasingly worried about what might actually be causing the headaches in the first place.
So, what was causing Lucy’s headaches?
The first thing was not to assume they were coming from her neck.
Headaches have many different causes and, with Lucy experiencing symptoms almost every day for a year, taking a thorough history and screening for anything requiring further medical investigation was an important part of her assessment.
Lucy was already under the care of her GP and had been referred to neurology, so that process needed to continue regardless of what I found during my assessment.
Before concentrating on Lucy’s neck and movement, I carried out some basic health and neurological screening. This included checking her blood pressure and assessing relevant aspects of neurological function, including things such as sensation, strength, reflexes, coordination and cranial nerve function where appropriate.
Nothing from my screening suggested any concern, but this didn’t replace the investigations already being arranged by her GP.
Her frequent use of pain relief was also important. Regular use of some headache medication can itself contribute to persistent headache patterns, so this was another factor that needed to be considered rather than simply assuming that everything was coming from her neck.
What else was her body telling us?
Once I was satisfied that it was appropriate to continue with a musculoskeletal assessment, there were some interesting clues.
When I first looked at Lucy, she habitually held her head tilted towards the right. There was obvious tension through her neck and shoulder muscles, which was confirmed during examination.
But the asymmetry wasn’t limited to her neck.
There was a noticeable difference in how she used the two sides of her body, with reduced movement through her left side. That made me interested in what Lucy was doing for the other eight hours of her day.
She worked at a computer.
I suspected that the positioning of her screen and other equipment might be encouraging her to repeatedly turn and orientate herself towards the right, while making relatively little use of the opposite side of her body.
There was another useful clue in her history:
Her headaches usually developed later in the day.
Why was I interested in that?
Because our movement behaviour at work can be very different from our movement at home or at weekends.
At a desk, we can spend hours repeating a relatively small number of positions and movements. Away from work, we tend to move more frequently and use our bodies in a greater variety of ways.
I asked Lucy whether her headaches were noticeably better at weekends. She couldn’t confidently say they were, so this wasn’t enough to provide an answer on its own.
But it was another piece of the puzzle.
What did we find when we assessed her?
Lucy’s examination showed restriction and muscular tension through her neck, shoulders and upper back, alongside the asymmetrical movement pattern I had already observed.
Taken together with her history, working habits and the way her symptoms tended to develop as the day progressed, these findings made me consider whether her neck and upper-body mechanics were contributing to this particular headache pattern.
Importantly, that didn’t mean every headache Lucy experienced was coming from her neck.
She had a history of migraine and was awaiting neurological assessment. Both remained relevant.
What we now had was a reasonable working hypothesis that at least some of the symptoms she was experiencing every day might have a musculoskeletal component.
Putting the pieces together
My assessment suggested that Lucy’s prolonged working positions and repeated movement habits could be contributing to the muscular tension, stiffness and sensitivity around her neck and upper back.
But I wouldn’t simply describe this as “bad posture.”
The bigger issue appeared to be a lack of movement variety.
Day after day, Lucy was spending long periods in similar positions, favouring one direction and making relatively little use of the other side of her body.
The headache she was describing also behaved differently from the migraines she already knew. Its location, behaviour and association with her neck and shoulder symptoms meant that a musculoskeletal contribution was worth addressing.
We therefore had something we could test.
If we changed some of those factors, would her headache change too?
What we did
During that first session, I explained what I had found and, importantly, what I hadn’t found.
That conversation mattered.
Lucy had become increasingly worried about her daily symptoms. Having a clearer understanding of what might be contributing to this particular headache pattern gave her something practical she could begin to address, while still continuing with the medical investigations recommended by her GP.
Treatment focused primarily on the sensitive and restricted areas around her neck and upper back.
I also gave Lucy a very simple shoulder-shrugging exercise to perform several times throughout the day. This wasn’t simply an exercise to “strengthen” something. Its purpose was to interrupt those prolonged working positions and improve her awareness of how she was holding and moving her body.
We discussed her desk set-up and ways she could introduce more movement and variation into her working day. I also specifically asked her to notice how much, or little, she used her left hand side.
Our initial plan was to see Lucy three times over the first two weeks, before gradually spacing her appointments over a further four weeks as we addressed the longer-standing restrictions and movement habits we had identified.
Lucy left that first appointment with some simple exercises, ergonomic advice and, perhaps most importantly, a greater sense of control over her symptoms.
What happened next?
Following that first session, Lucy reported that in the three days since her treatment she had not experienced a single headache.
That didn’t mean that a problem she had experienced for a year had somehow been “fixed” in one appointment.
What it did give us was useful information.
Changing some of the factors we suspected were contributing to her symptoms appeared to change the headache too.
As Lucy began adjusting her desk set-up, moving more regularly and becoming more aware of her habitual positions, she was increasingly able to recognise and manage the things that seemed to aggravate her symptoms.
We continued with the treatment plan, initially seeing her more frequently before spacing appointments as her symptoms became more manageable.
For someone who had spent months worrying about why she was experiencing headaches every day, regaining that sense of control was significant.
What can Lucy’s case teach us about headaches?
Not every headache felt around the base of the skull is caused by the neck, and posture should not automatically be blamed.
There are many different types and causes of headache.
However, for some people, the neck, upper back, surrounding muscles and the way we move, or don’t move, throughout the day may contribute to their symptoms.
That’s why assessment matters.
An osteopathic assessment can look at the movement of the neck and upper back, muscular and joint function and whether particular movements or positions influence your familiar symptoms.
But assessment isn’t simply about finding something to treat.
It’s also about recognising when the presentation doesn’t fit a straightforward musculoskeletal pattern and when further medical assessment is appropriate.
When should you seek medical advice for a headache?
There are many different types and causes of headache, and not all are appropriate for osteopathic treatment.
A headache that is new, sudden, unusually severe, persistent or significantly different from your normal headaches should be medically assessed.
You should also seek appropriate medical attention if a headache is accompanied by symptoms such as changes in vision or speech, weakness or numbness, loss of coordination, confusion, fever or significant illness.
And if you are regularly relying on painkillers to control your headaches, that’s also worth discussing with your GP or pharmacist.
If you’re unsure about a headache, seek medical advice rather than assuming it is coming from your neck.
Could your neck be contributing to your headaches?
If you experience recurring headaches alongside neck pain, stiffness or symptoms that seem to build as the day progresses, an assessment may help establish whether your neck, movement and daily habits could be contributing.
The aim isn’t simply to treat the painful area.
It’s to understand why your symptoms may be occurring, what might be maintaining them, and what you can do about it.
If you are suffering with headaches and would like to chat to one of our osteopaths about how we might be able to help you, click on the link below to book a free 15 minute consultation or make an initial appointment.