Patient History
A 63-year-old male presented to the physical therapist with a primary complaint of insidious onset headaches over the past 5 months while typing at the computer with a secondary complaint of chronic neck and shoulder tightness. The headache pain was described as a diffuse, dull ache originating near the medial aspect of the superior spine of the scapula bilaterally and progressively radiating upward toward the occiput. The patient reported a steady increase in symptoms while typing that peaked in the afternoon and decreased in the evening after self-administered treatment. Past medical history included concussion and an acute bout of neck pain after a traumatic biking accident 5 years prior. Imaging ruled out red flags and aside from some intermittent lingering stiffness, a full recovery was achieved.
Relief from headache symptoms occurred while taking a hot shower, using a heating pad, or applying self-massage to muscles in the neck and scapulothoracic region. At worst, headache pain was 6/10 on the Numeric Pain Rating Scale (NPRS) and negatively affected the patient’s ability to concentrate while working. The NPRS is a reliable and valid instrument to assess pain intensity.46-48 The minimal clinical important difference (MCID) for the NPRS has been shown to be 1.74 in patients with chronic pain conditions;47however, the MCID for tension type headache pain has not yet been established. Nevertheless, a change of 2 points or a 30% decrease in pain from baseline can be considered as a MCID in patients with chronic musculoskeletal pain.47,49
The Neck Disability Index (NDI) score at the initial examination (i.e., baseline) was 19/50 (38%). The NDI is the most widely used instrument for assessing self-rated disability in patients with neck pain.50-52 The NDI is a self-report questionnaire with 10 items rated from 0 (no disability) to 5 (complete disability).53 The numeric responses for each item are summed for a total score ranging between 0 and 50.50,54 Higher scores represent increased levels of disability. The NDI has been found to possess excellent test-retest reliability, strong construct validity, strong internal consistency, and good responsiveness in assessing disability in patients with cervicogenic headache.48 Although the MCID for CTTH has not yet been determined, the MCID for the NDI has been reported to be 7.5 in patients with cervicogenic headache.48