When is someone with headaches not a candidate for PT?

There are conditions that may result in neck pain and/or headaches that are medical emergencies and not candidates for PT. These are cervical artery dissections (stroke), upper cervical instability and cervical myelopathy. The signs and symptoms we look for include: 

• Cervical Artery Dissection (stroke): 
  • High blood pressure
  • Cardiovascular risk factors 
  • Changes in cranial nerves (cranial nerves include nerves responsible for smell, eye movement, taste, tongue movement, hearing and some muscles in the neck region. 
  • The “5 D’s” (dizziness, drop attacks (unexplained loss of consciousness, double vision, difficulty swallowing, difficulty speaking) 
  • The “3 N’s” (nausea, numbness, nystagmus (involuntary movements of the eyes))
  • Ataxia (lack of voluntary coordination of muscle movements resulting in gait abnormalities and/or speech changes
• Upper Cervical Instability:
  • History of trauma
  • History of hypermobility disorders such as Ehler Danlos Syndrome (EDS), rheumatoid arthritis or down’s syndrome.
  • Changes in cranial nerves (cranial nerves include nerves responsible for smell, eye movement, taste, tongue movement, hearing and some muscles in the neck region. 
  • The “5 D’s” (dizziness, drop attacks (unexplained loss of consciousness), double vision, difficulty swallowing, difficulty speaking) 
  • The “3 N’s” (nausea, numbness, nystagmus (involuntary movements of the eyes))
  • Ataxia (lack of voluntary coordination of muscle movements resulting in gait abnormalities and/or speech changes
• Cervical Myelopathy: 
  • Bilateral numbness and/or tingling in both hands and/or both feet
  • Disturbances in gait (walking)
  • Clumsiness in the hands (such as difficulty buttoning shirt) 
  • In severe cases, one may experience difficulty initiating urination, incontinence and inner-groin numbness 

Other concerns include spinal metastasis, infection and side-effects from medication. Symptoms we look for are fever, chills, night sweats, unexplained weight loss, recent infection and/or history of cancer. 

Medication-specific concerns include:

• Steroids: risk of osteoporosis
• Anti-coagulants: risk of bleeding
• Immunosuppressants: risk of infections

References:

1. “Neck Pain Guidelines: Revision 2017: Using The Evidence To Guide Physical Therapist Practice,” Vol 47, no. 7, 2017, pp. 511-512. Journal Of Orthopaedic & Sports Physical Therapy (JOSPT), https://doi.org/10.2519/jospt.2017.0507.

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