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