Title : Multimodal physical therapy for chronic cervicogenic headache misdiagnosed as migraine: A case report
Abstract:
Background: Cervicogenic headache (CGH) is a secondary headache caused by cervical musculoskeletal dysfunction and commonly misdiagnosed as migraine due to many overlapping symptoms. Incorrect diagnosis could prolong effective treatment, increase the medication load on the patient and contribute to chronic pain and symptom-related distress. In nursing practice, early recognition of musculoskeletal problems is especially important to prevent disability and functional limitation due to chronic symptoms. This case report talks about the assessment and rehabilitation of a patient with chronic unilateral headaches initially managed as migraine but later identified as CGH, with emphasis on multimodal conservative care and its relevance to interdisciplinary orthopedic nursing and rehabilitation care.
Case Description: The patient was 32-year-old women with a history of right sided headaches, neck pain and stiffness for the past 5 years that gradually worsened and was affecting her daily functional, work tasks and disrupted her sleep. The patient worked a full-time computer-based job which would aggravate her symptoms. Previous treatment with Magnesium glycinate and non-steroidal anti-inflammatory drugs (NSAIDs) provided no lasting relief. Brain MRI was unremarkable, while cervical imaging demonstrated increased cervical lordosis, early degenerative changes at C3-C4-C5 spinal levels. Physical therapy examination demonstrated forward head posture, rounded shoulders, limited cervical range of motion, positive cervical flexion-rotation test (CFRT), impaired craniocervical flexion performance (CCF), scapular weakness, and tenderness of the upper and lower cervical musculature, supporting the diagnosis of CGH.
Intervention: The patient completed a 12-week multimodal rehabilitation program delivered twice weekly for 8 weeks followed by once weekly for 4 weeks. Management included upper cervical and thoracic mobilization, soft tissue mobilization, passive stretching, deep neck flexor retraining with pressure biofeedback, progressive scapular strengthening, postural re-education, ergonomic modification, and a structured home exercise program. Ongoing symptom monitoring and reinforcement of self-management strategies were incorporated throughout care to support adherence and long-term recovery.
Outcome: By discharge, the frequency of headaches lowered from 7 days to 1 day per week along with a significant drop in the intensity of her headaches from 8/10 to 2/10 on the Numeric Rating Scale (NRS) while the Neck Disability Index (NDI) improved from 54% to 10%. Improvements were also observed in the cervical mobility, tolerance for daily and desk work activities and quality of sleep.
Clinical Significance: This case emphasizes the clinical importance for identifying headaches with cervicogenic origin in patients with chronic headaches who fail to respond to migraine specific interventions. Conservative rehabilitation with a multimodal approach showed big improvements in pain and disability levels, sleep pattern and overall functional outcomes. For orthopedic nursing and interdisciplinary practice, this case highlights the importance for a nurse to accurately identify musculoskeletal symptoms early, monitor patient’s response to medical treatment and ensure timely referral for rehabilitation. With an increased awareness of CGH among the nursing and other musculoskeletal settings, an earlier diagnosis of CGH may be possible, ensuring reduction in unnecessary dependence on symptomatic medications and improved patient-centered outcomes.
