Case History:

40 yo presents with chronic headaches and associated neck pain

Contributed By:
Lawrence Bagnell, DC
Case Presentation: Page 1 of 4

Patient Overview:
A 40-year-old male presents with chronic headaches and associated neck pain. His medical history includes multiple motor vehicle accidents, with one incident involving whiplash. He works as an IT programmer, spending prolonged hours in front of a computer screen.

Chief Complaint:
Headaches originating around the eyes and radiating over the scalp into the posterior neck. The patient also reports chronic neck discomfort.

Medical History & Previous Management:

  • Underwent a comprehensive medical evaluation with partial symptomatic relief from prescribed medications.
  • Continue to experience intense headaches despite medical management.
  • Denies photophobia or visual disturbances but reports regular use of corrective lenses for farsightedness.
  • Family history is significant for headaches and cardiovascular disease (father, deceased).

Physical Examination Findings:

Vital Signs:

  • Weight: 195 lbs
  • Height: 6'0"
  • Temp: 98.5°F
  • Pulse: 77 bpm
  • BP: 135/75 mmHg

Neuromusculoskeletal Assessment:

  • Positive cervical compression, foraminal compression, Jackson’s cervical compression, and cervical decompression tests.
  • Palpation reveals bilateral myospasms in the levator scapulae, trapezius, and posterior cervical musculature extending into the upper back.
  • Hypermobile cervical range of motion with tenderness noted along the posterior cervical spine and bilateral upper back musculature.
  • Negative George’s and Valsalva’s tests.
  • Normal lower back range of motion.

Behavioral Note: Patient frequently self-manipulates (cracks) his neck, reporting temporary relief.

Question: Based on this clinical history, what are some of the differential diagnoses that you are considering?

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