R51 and Done? Headaches aren't that simple!

Headache and Differentials

Headaches are a symptom, NOT a diagnosis; usually. What that means is the head pain felt by patients is often due to some causative factor. When patients present with headache as their primary complaint, the first two questions I ask are:

  1. Does this run in your family?

  2. When was your last eye exam?

The answer to the first question is to see if there is possibly a genetic component to the headache. Some headaches seem to be familial and therefore are beyond the resolve of manual therapy. The second is a clinical pearl I’ve picked up from seeing a number of adolescent and young adult patients who try to outsmart the optometrist. The overuse and inappropriate wear of contacts and eyeglasses have been a cause for enough headache cases in my office that it bears mentioning. Again, no amount of manual therapy will resolve these issues.

That said, understanding the types of headaches will give the practitioner better expectations about the prognosis from their care. Primary causes of headaches may include:

  • Migraine

  • Cluster

  • Tension-Type

  • Trigeminal-Type

  • Chronic

Secondary causes of headache may include:

  • Inflammation or head/neck injury

  • Stroke (vascular migraine)

  • Sinus/Nasal

  • CNS Infection

  • Drug-based (withdrawal or overuse)

  • Menstrual/Hormone

  • Cervicogenic/Cephalgia


R51 and done?

Review the list of ICD-10 codes for headaches. Many secondary causes are listed with their own high level codes. Even some primary, like migraines, can be detailed extensively. However, when it comes to the other types of headaches (especially those seen in the manual therapist’s office) it’s depressingly lacking. I suppose it’s easy to have just a single code, but it feels as though the level of expertise in differentiating these headaches is lost.

How can I help?

One of the things I explain to students is that not all headaches can be cured. However, that doesn’t mean their symptoms can’t be improved upon. If during the examination it’s determined that the headache is primary to a non-MSK issue, then expectations should be laid out that only some elements may improve. Here, let’s ask the patient specifically the 1) Frequency 2) Intensity and 3) Duration of their headaches. Usually, at least one of these factors will be improved following a course of conservative care. Then, a comprehensive evaluation of those muscles causing increased sensitivities should be performed and treatments (pick your favorite soft tissue and exercises and see if they work) attempted until some level of of relief is found.


There is a separate post that describes the relationship of the dura and various musculoskeletal findings. Here, however, if the dura is addressed/treated it may be a very powerful therapy to those suffering from primary non-MSK headaches.