Differential Diagnosis
Potential diagnoses included CTTH, cervicogenic headache (CH), cervical facet arthropathy and cervical spondylosis. Notably, the patient presentation did not match the revised diagnostic criteria for CH63 developed by the Cervicogenic Headache International Study Group (CHISG)63-65 consisting of (1) unilaterality of head pain without side shift, starting in the upper posterior neck or occipital region, eventually spreading to the oculofrontotemporal area on the symptomatic side, (2) pain triggered by neck movement and/or sustained awkward positions, (3) reduced range of motion in the cervical spine66 (i.e., less than or equal to 32 ° of right or left passive rotation on the Flexion-Rotation Test),67-69 (4) pain elicited by external pressure over at least one of the upper cervical joints (C0-3), and (5) moderate to severe, non-throbbing and non-lancinating pain. Nevertheless, the diagnosis was guided by the patient’s subjective presentation of bilateral headache pain, the IHS criteria for CTTH including (1) headache occurring ≥15 days per month on average for >3 months (2) lasting hours to days and (3) demonstrating at least two of the following four characteristics: bilateral location, pressing or tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity,2 and specific reproduction of the patient’s headache symptoms with palpation of the levator scapulae muscle and it’s enthesis.