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CLINICIAN EXPERTISE COMMENTARY 

 

73 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 
 

Concussion Clinical Pathway: Headache and Cervical Assessment 
Framework  
Nicholas Hattrup, MS, ATC*; Nicholas Pfeifer, EdM, ATC†; Tamara Valovich McLeod, PhD, ATC, FNATA‡ 
*University of Oregon, Eugene, Or; †Athletic Training Services, Boston University, Boston, Massachusetts; ‡Athletic Training 
Programs and School of Osteopathic Medicine, A.T. Still University, Mesa, AZ  
 

 
ABSTRACT 
The prevalence of sport specialization is a common concern in contemporary youth sports and has been linked to potential negative 
physical and psychological effects for developing athletes. While the evidence regarding negative physical effects, such as overuse 
injury, are consistent in the literature, the psychosocial outcomes are unclear due to the lack of published studies on the topic. 
Specialization is thought to lead to added stress, which may affect an athlete’s mental health, whereas athletes who sample multiple 
sports are believed to have a healthier psychosocial experience. Burnout is characterized as physical and emotional exhaustion, 
sport devaluation and a reduced sense of accomplishment in athletics. This guiding review evaluates the evidence regarding burnout 
levels between specializers and samplers. Two of the articles included in the review directly assessed burnout in samplers vs 
specializers and noted inconsistencies in higher burnout rates. The six other articles studied burnout only in specializers by indirectly 
assessing burnout through perfectionism, fear of failure, motivation, and drop out. The comparisons of these variables illustrated 
heightened burnout in athletes who specialize. The results from these studies provide moderate evidence for recommendations that 
athletes should delay specializing in one sport. 
Content Focus: Health Care Competency  
 
Correspondence 
Nicholas Hattrup, Boston University Athletic Training Services, 285 Babcock Street, Boston, MA 02215. 
E-mail: sa199462@atsu.edu  
Twitter: @_nhattrup 
 
Full Citation 
Hattrup N, Pfeifer N, Valovich McLeod T. Concussion clinical pathway: headache and cervical assessment framework. Clin 
Pract Athl Train. 2023;6(1): 73-79. https://doi.org/10.31622/2023/0006.01.11.  
 

Background  
 
The emphasis on the identification of vestibular-oculomotor dysfunction following concussion has brought 
attention to impairments associated with headache disorders and the cervical spine. Utilizing a classification-
based approach for headaches can help to identify impairments associated with a patient’s headache.4 
Furthermore, encouraging the importance of impairments for headache disorders following concussion may 
help to adopt organized treatment approaches. A previous study identified athletic trainers who perceived 
a greater importance in identifying cervical impairments were more likely to use an intervention targeted 
the cervical spine following a concussion.1 The reassessment of the cervical spine to ultimately treat concussive 
symptoms is needed due to the potential presence of cervical impairments with symptoms of headaches and 
dizziness. Creating a systematic approach to the assessment of headache disorders while acknowledging 
regional influences such as the cervical spine may help clinicians in implementing headache assessments. The 
purpose of this article is to describe the various differentials for headache disorders following a concussion, 
as well as the contributions of the cervical spine to headache and dizziness symptoms.  

Clinical Assessment 

When examining the cervical spine for possible symptom generators, various neurological and orthopedic 
impairments can generate headache and dizziness symptoms. The following sections will discuss headache 
and migraine disorders defined by the Internal Classification of Headache Disorders as well as regional 
dysfunctions of the cervical spine (i.e., cervical facet pain and cervicogenic dizziness).4 

Headache and Migraine Disorders 

mailto:sa199462@atsu.edu
https://doi.org/10.31622/2023/0006.01.11


Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

74 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

The International Classification of Headache Disorders (ICHD) has developed criteria for the assessment of 
primary and secondary headaches,4 with secondary headaches caused by a co-presenting disorder.4 An 
example of a secondary headache disorder, is a post-traumatic headache which occurs in close temporal 
relation to the site of trauma or injury.4 Various presentations of post-traumatic headache can occur, including 
cervicogenic headache, tension-type headache, headache attributed to cervical myofascial pain, occipital 
neuralgia, cluster headache, headache attributed to temporomandibular disorder, headache attributed to 
eye disorders, medication overuse headache and migraines (Table 1).  

Classification of Headaches 

In patients with cervicogenic headache, the symptoms present unilateral with symptom location wrapping 
from the base of the skull around the ear to the lateral eye (i.e., ram’s horn sign).4 The clinical assessment of 
this pathology follows a local assessment to the cervical spine, with the addition of a cervical flexion rotation 
test as it is shown to have high discriminatory ability to identify cervicogenic headache.3  

Tension-type headaches usually present bilaterally with patient descriptors of “pressing” or “tightening” with 
non-pulsating quality.4 Of importance, the absence of nausea and vomiting is important as if these symptoms 
are present, it may indicate migraine like symptoms.4 When utilizing pharmacological intervention, the use 
of ibuprofen early on either alone or in conjunction with acetaminophen has shown better outcomes than the 
use of acetaminophen alone for tension headaches.7  

Regarding headaches attributed to cervical myofascial pain, the headaches often start in relationship to the 
onset of cervical myofascial pain and pressure on the involved cervical muscles may increase the headache 
intensity. 4  

In patients with occipital neuralgia, the presentation can be unilateral or bilateral within the sensory 
distribution of the greater, lesser and/or third occipital nerves.4 Patients will describe recurring paroxysmal 
attacks lasting for a few seconds, severe in intensity, and shooting, stabbing, or sharp in quality.4 
Additionally, tenderness over the affected occipital nerve branches and/or trigger points at the emergence 
of the greater occipital nerve should be present. 4  

While uncommon, there has been anecdotal cases of cluster headaches following traumatic head injury which 
is described as a unilateral headache presenting over the orbits and supraorbital region lasting from 15-
180 minutes. 4 An important distinction of this headache is the presentation of ipsilateral cranial autonomic 
for example forehead and facial sweating. 4  

With headaches attributed to temporomandibular disorder, the headache presents in relationship to a 
temporomandibular disorder and is aggravated by active and passive movement of the jaw along with the 
palpation of muscles associated with mastication 4 Typically, the headache is most prominent in the temporal 
regions, preauricular areas of the face, and/or masseter muscles.4 When patient’s present with 
temporomandibular disorders assessment of the atlantooccipital and atlantoaxial joint should be performed, 
previous research has identified co-morbid impairments within the upper cervical spine in temporomandibular 
disorders with headaches.8 

Headaches can often be accompanied with visual deficits or decreased oculomotor function. With headaches 
attributed to eye disorders, the patient may complain of either blurred vision, diplopia, or difficulty switching 
from near to far focus.4 This headache will be aggravated by sustained visual tasks and improve with the 



Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

75 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

cessation of the visual task.4 These types of headaches are best resolved with treatment and improvement 
of the visual impairment whether it be refractive error, oculomotor phoria, or other oculomotor impairments 
indicating the need for optometric assessment.4  

Patients that have been taking over the counter medication for an extended period following their injury 
and continue to present with a headache may present with medication over-use headache. Patients with 
medication-overuse headaches typically present with a headache occurring greater than or equal to 15 
days/month with a pre-existing headache disorder and regular overuse of analgesic medication for greater 
than 3 months. 4  

Migraine 

It is important for providers who treat patients following concussion to realize a subset of patients may 
present with a headache with migraine like symptoms.9 A main difference in the assessment and treatment 
of migraines is with migraines the focus is on reducing the frequency of migraine episodes through the 
identification and avoidance of personal and environmental triggers. The clinical criteria for migraine with 
and without aura (i.e., sensory disturbances) can be found in Table 1. In recent years, cervical afferents 
within migraine disorders have been identified as an important regional impairment.10 At this time there is 
no gold standard clinical approach to the physical assessment of cervical impairments in migraine disorders, 
therefore a comprehensive cervical spine assessment should be performed.10 Treatments which have shown 
promise for the reduction of migraine symptoms and episodes span from the use of medications, dry needling, 
botulinum toxin injections, and lifestyle modifications (i.e., diet and fitness). 

Regional Influences 

Pain from the cervical facet joints has been shown to radiate into the upper thoracic spine as well as the 
posterior skull. Specifically, C2-C4 can generate pain in and around the occiput, temporalis, and trapezius 
regions. Currently when examining the facet joints, the extension rotation test and unilateral posterior to 
anterior mobilizations eliciting the patient’s symptoms (i.e., concordant sign) have shown the most clinical 
utility to identify cervical facet dysfunction.5 If patients present with pain stemming from the cervical facet 
joint, joint mobilization and/or manipulation of the cervical spine as well as targeted treatment to the tonic 
(i.e., spastic) musculature has shown promise.3 

When examining the upper cervical spine, an important dysfunction to consider is cervicogenic dizziness since 
it may present alone or in conjunction with vestibular dysfunction. For cervicogenic dizziness the cause of 
dizziness stems from impairment of the upper cervical structures which can influence both the oculomotor and 
vestibular systems causing generalized dizziness. The assessment of cervicogenic dizziness should utilize a 
multi-clinical test framework. The use of the head neck differentiation test can indicate the presence of 
possible cervical involvement, while the use of the cervical neck torsion test and smooth pursuit neck torsion 
test can assess the influence of the upper cervical afferent system on oculomotor control.6 Further, the use of 
the cervical joint position error test can determine sensorimotor impairment.6 When creating a treatment plan 
for a patient with cervicogenic dizziness, joint mobilization and manipulation targeted to the upper cervical, 
soft tissue mobilization, and/or dry needling have shown promise.3 Active exercises to reestablish kinesthetic 
sense should be prescribed in conjunction with passive interventions, furthermore oculomotor/head-shake 
exercise has shown promise for treating cervicogenic dizziness.3 



Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

76 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

 

 

Sinister Pathology 

While the focus of this article is on the post-acute identification of headache disorders, and the contribution 
of the cervical spine to headaches and dizziness, readers should understand severe pathology such as 

Table 1. Characteristics of Migraines and Headaches 

 Aura Site 
Characteri

stics 
 

Aggravating 
Factors 

Nausea 
or 

Vomiting 

Photo or 
Phono -
phobia 

Autonom
ic 

Features 

Migraine Possible Unilateral Pulsatile Movement Yes Yes Yes, 
subtle 

Tension No Bilateral: Band 
Like 

Pressure, 
Tightening 
Sensations  

Movement No No No 

Cervicogenic No 
Unilateral: 
Occipital to 

Orbital Region 

Tightening, 
Burning 

Sensations 

Head 
Movement No No No 

Medication 
Overuse No Diffuse (Non-

Specific) 

Pressing, 
Tightening, 
Pulsating 

Pain 

No No No No 

Cluster No 

Unilateral: 
Orbital, 

Supra-orbital, 
Temporal 
Regions 

Stabbing 
Pain No Maybe Maybe Yes 

Occipital 
Neuralgia No 

Unilateral/Bila
teral: Greater, 
Lesser, Third 

Occipital 
Nerve Regions 

Shooting, 
Stabbing, 

Sharp 
Pain 

Palpation No No No 

Headache 
attributed to 

Temporomandi
bular Disorder 

No 

Unilateral/Bila
teral: 

Temporal, Pre-
auricular, or 

Masseter 
Regions 

Variable Jaw 
Movement No No No 

Headache 
attributed to 
Eye Disorder 

No 

Unilateral/Bila
teral: Orbital 
and Frontal 

Regions 

Variable 
Visual & 

Oculomotor 
Tasks 

No No No 

Headache 
attributed to 

Cervical 
Myofascial 

Pain 

No 

Unilateral/Bila
teral: Pain 
Referral 

Regions from 
Neck and/or 

Face 
Musculature 

Variable 
Referred Pain 
from Muscle 
Palpations 

No No No 



Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

fractures, vascular and ligament injuries as potential differentials. The Canadian C-Spine rules and 
International Federation of Orthopedic Manipulative Physical Therapists Vascular Framework are useful 
resources for the assessment of severe osseous and vascular pathologies.2,3 Without a gold standard clinical 
test for upper cervical spine integrity,3 if upper cervical spine instability is suspected, flexion, extension and 
odontoid x-ray views should be ordered to rule out serious pathology to the ligament structures.  

Outline of Evaluation 

While the above information provides a broad overview of headache disorders, a simple streamlined 
evaluation can differentiate headache disorders (Figure 1). The post-acute clinical assessment of a patient 
with a headache following a concussion should consider the mechanism of injury and comorbid symptoms. If 
the mechanism were traumatic, but the patient has full range of motion of the neck they would be considered 
low risk for cervical fracture based on the Canadian C-Spine rules and a further cervical assessment should 
continue. Next, determining if the patient has any possible signs (e.g., changes in blood pressure, carotid 
artery auscultation differences) and symptoms (e.g., ataxia, weakness, dysphasia, dysarthria, and aphasia) 
necessitating further examination for vascular pathology is important.2 If it is determined the patient is at a 
low risk for vascular pathology, the next consideration is upper cervical instability. While the use of Sharp-
Purser and Transverse Ligament selective tissue tests may be sensitive for upper cervical instability, they 
should be interpreted with caution due to low clinical utility in ruling out pathology.3 Lastly, an upper quarter 
and lower quarter screen could be performed to assess reflexes, myotomes, and dermatomes. 

Further assessment should be informed by the patient’s clinical presentation. Understanding if the headache 
is unilateral versus bilateral would help to differentiate tension-type headache versus other headache 
disorders. Additional key history information of prolonged analgesic use for headaches, worsening symptoms 
with oculomotor tasks which resolve after activity, and sharp intense headaches over the orbit and forehead 
area with facial sweating may suggest other headache disorders.  

The patient should be seated at the start the evaluation to complete range of motion and if dizziness is 
present, the assessment could include the head-neck differentiation test, cervical neck torsion test, smooth 
pursuit neck torsion test, and/or joint position error assessment before further manual physical examination 
is completed to decrease patient irritability. Lastly, if the patient describes the headache in the area where 
a cervical facet joint can generate pain in the lower occiput and temporal regions, the extension rotation 
assessment could be performed in the same position. 

Once these assessments are performed, palpation of the greater and lesser occipital nerves along with the 
sub-occipital and trapezius muscles in sitting can be completed. Following this the patient can be placed in 
supine where the clinician can assess cranial cervical flexion and perform the cervical flexion rotation test 
for cervicogenic headache. In this position palpation of the orofacial muscles (i.e., temporalis, masseter, and 
pterygoid) are recommended to be performed. The patient can then be placed in a prone position where 
unilateral posterior to anterior mobilizations can be performed if further assessment for cervical facet and 
migraine is warranted.   

While the above examination is inclusive of the various headache and migraine disorders discussed, clinical 
expertise and judgement should be used to determine which assessments should be performed and which 
differentials should be considered. The data obtained from the patient’s history should help with planning 
for the physical examination as well as the specific order and priority for testing. Decreasing the potential  



Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

Figure 1. Evaluation Flow Chart 

 



Concussion Clinical Pathway: Headache and Cervical Assessment Framework 

 

79 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

for patient irritability when performing a physical examination is important to reduce the confounding results 
throughout the physical examination.  

Lastly, various outcome measures can be utilized to gauge patient disability, treatment effectiveness, and 
monitor patient progress.11 Interventions for post-traumatic headache are diverse consisting of cognitive 
behavioral therapy, massage, non-steroidal and steroidal medications, aerobic and therapeutic exercise, as 
well as manual therapy and dry needling based on the impairments. For patients with persistent headache 
or migraine symptoms a multidisciplinary approach may be warranted.    

Conclusion 

Like other pathways for concussion assessment, further assessment of headaches can allow for more targeted 
treatment. The use of an appropriate history and physical examination with consideration of differentials 
may help to improve outcomes, especially in the presence of headache disorders and cervical impairments.  

References 

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management of sports-Related concussion. J Sport Rehab. 2021;30(6):926-934. 
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2. de Best RF, Coppieters MW, van Trijffel E, et al. Interexaminer agreement and reliability of an 
internationally endorsed screening framework for cervical vascular risks following manual therapy and 
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7. Petrelli T, Farrokhyar F, McGrath P, et al. The use of ibuprofen and acetaminophen for acute headache 
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11. Valovich McLeod TC, Vesci B. Concussion profiles: moving beyond the graded symptom scale. Clin Pract 
Athl Train. 2022;5(1). https://doi.org/10.31622/2022/0005.01.5.  

https://doi.org/10.1123/jsr.2020-0394
https://doi.org/10.1093/ptj/pzab166
https://doi.org/10.2519/jospt.2017.0302
https://doi.org/10.1177/0333102417738202
https://doi.org/10.1016/j.apmr.2014.02.026
https://doi.org/10.1186/s40945-017-0040-x
https://doi.org/10.1093/pch/pxw011
https://doi.org/10.1179/0886963414Z.00000000053
https://doi.org/10.1177/0333102413499645
https://doi.org/10.1186/s40945-021-00123-0
https://doi.org/10.31622/2022/0005.01.5

	ABSTRACT

