This week we will continue our discussion of headaches by reviewing typical patient presentations for headaches commonly treated by doctors of chiropractic and review strategies for evidence-based clinical decision-making, including identification of red flags. Lets start with a common scenario: a patient walks into a chiropractic office complaining of a headache. What’s the next step?

Clinical guidelines (1-4) recommend beginning with a comprehensive patient history, followed by a thorough neurologic and physical examination. (5) This information allows the clinician to classify the headache according to the International Headache Society (2), identify red-flags and rule out pathologies. It is not possible to over-emphasize the importance of taking a complete history and conducting a thorough examination in the diagnosis and treatment of patients with headaches.

While emerging research exists on the treatment of migraines (6), chiropractors are primarily involved in the treatment of headaches related to structural causes – tension-type and cervicogenic. Tension-type headaches are defined by the International Headache Society as primary headaches which present bilaterally with mild to moderate intensity, lasting minutes to days. They are described as a sensation of pressing or tightening, and pain typically does not affect day-to-day activities. Upon palpation, pain can be elicited across the skull and cervical spine musculature. (2)

Secondary cervicogenic headaches are caused by a disorder of the cervical spine. Usually accompanied by neck pain, their defining feature is the involvement of bones, discs or soft-tissue structures in the cervical spine (2). In many cases tension-type and cervicogenic headaches overlap, making formal diagnosis a challenging task based on symptoms alone.

Although the incidence is low, the evidence-based chiropractor should always rule out the possibility of a cervical artery dissection, especially when encountering a patient with the onset of severe headache or neck pain (7). Artery dissection occurs when a tear develops within the wall of either the carotid or vertebral arteries. Inquiring about the specific onset, location, severity, duration and any other symptoms like vision changes or facial numbness (8)* can provide guidance to a preliminary diagnosis. If a dissection is suspected, an immediate emergency referral should be made.


1. Differential Diagnosis and Management for the Chiropractor: Fifth Edition. Souza, Thomas A; 2016.

2. Olesen J, et al. The International Classification of Headache Disorders, 3rd edition. Cephalgia: Headache Classification Committee of the International Headache Society (IHS); 2018.

3. Walling A. Frequent Headaches: Evaluation and Management. Am Fam Physician. 2020 Apr 1;101(7):419-428. PMID: 32227826.

4. Côté P, Yu H, Shearer HM, Randhawa K, Wong JJ, Mior S, Ameis A, Carroll LJ, Nordin M, Varatharajan S, Sutton D, Southerst D, Jacobs C, Stupar M, Taylor-Vaisey A, Gross DP, Brison RJ, Paulden M, Ammendolia C, Cassidy JD, Loisel P, Marshall S, Bohay RN, Stapleton J, Lacerte M. Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for
traffic injury management (OPTIMa) collaboration. Eur J Pain. 2019 Jul;23(6):1051-1070. doi: 10.1002/ejp.1374. Epub 2019 Feb 28. PMID: 30707486.

5. Potter R, Probyn K, Bernstein C, Pincus T, Underwood M, Matharu M. Diagnostic and classification tools for chronic headache disorders: A systematic review. Cephalalgia. 2019 May;39(6):761-784. doi: 10.1177/0333102418806864. Epub 2018 Oct 18. PMID:30335472; PMCID: PMC6710619.

6. Rist PM, Hernandez A, Bernstein C, Kowalski M, Osypiuk K, Vining R, Long CR, Goertz C, Song R, Wayne PM. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache. 2019 Apr;59(4):532-542. doi: 10.1111/head.13501. Epub 2019 Mar 14. PMID: 30973196; PMCID:

7. Vidale, S. Headache in cervicocrebral artery dissection. Neurol Sci 411, 395-399 (2020).

8. Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017 Feb;48(2):479-481. doi: 10.1161/STROKEAHA.116.015169. Epub 2017 Jan 12. PMID:28082668.

Please note references are both image and text.