OpenEvidence discussion and associated neurology appointments

I asked OpenEvidence: “My headaches, supposed to be tension headaches, get worse after abrupt movement. Walking or jogging won't worsen them, but shaking head rapidly or moving in changing direction abruptly will. Abrupt head movements, and thus intense physical exercise, tends to worsen my headaches I believe. Also, NSAIDs or acetaminophen don't help my headaches. Soft tissue therapy by a kinesiologist or osteopath doesn't help. This started 14 months ago, with occasional periods without headaches including during 2 months after jaw surgery. I still have a dental malocclusion however. An MRI scan didn't show brain anomalies. The headaches are bilateral, at the front and temples. Do I really suffer from tension headaches, or would I suffer from another headache type? Ask me follow-up questions if necessary for proper diagnosis.”, and he answered: “
Most Likely Diagnoses:
1. Tension-type headache remains possible given the bilateral, frontal-temporal location and pressing quality. However, the International Classification of Headache Disorders (ICHD-3) criteria, as summarized by Ashina et al., specify that tension-type headache is not aggravated by routine physical activity, and simple analgesics are usually effective. In this case, the headaches are aggravated by abrupt head movements and are unresponsive to NSAIDs/acetaminophen, which is atypical for tension-type headache.
2. Cervicogenic headache is a strong consideration. Cervicogenic headache is often provoked by neck movement or sustained awkward head positions, and pain may radiate from the neck to the frontotemporal region. The clinical features most indicative are pain provoked by neck movement and pain radiating to the frontotemporal area, as described by Bogduk and Govind. The lack of response to analgesics and the association with abrupt head movements further support this diagnosis.
3. Temporomandibular disorder (TMD)-related headache is plausible, given the history of jaw surgery, ongoing dental malocclusion, and the known association between TMD and headache. TMD can present with bilateral, frontotemporal pain and may be exacerbated by jaw movement or malocclusion.
4. Migraine without aura is less likely due to the absence of migrainous features (unilateral, pulsating, moderate/severe intensity, nausea, photophobia/phonophobia, or clear aggravation by routine activity), as outlined by Ashina.
Most Important Not to Miss Diagnoses:
1. Intracranial mass lesion: Already excluded by a normal MRI brain.
2. Cerebral venous sinus thrombosis (CVT): Typically presents with subacute headache, often with focal neurologic deficits or papilledema. If MRI included MRV and was normal, CVT is unlikely. The American Heart Association recommends MRV or CTV for diagnosis.
3. Cervical artery dissection: Presents with headache/neck pain, often after trauma or abrupt neck movement, and may be associated with focal neurologic deficits or Horner syndrome. The American Heart Association recommends vascular imaging (MRA/CTA) if suspected.
Key Additional History and Tests:
- Clarify if the MRI included vascular imaging (MRV/MRA/CTA) to exclude CVT or cervical artery dissection.
- Ask about any associated neck pain, trauma, or neurologic symptoms (e.g., visual changes, limb weakness, Horner syndrome).
- Assess for TMD symptoms: jaw pain, clicking, limited movement, or pain with chewing.
In summary, the most likely diagnoses are cervicogenic headache and TMD-related headache, with tension-type headache less likely given the atypical features. Cervical artery dissection and CVT should be excluded if not already done with appropriate imaging.
Would you like me to review whether vascular imaging (such as MRA, CTA, or MRV) was performed alongside the MRI to definitively rule out cervical artery dissection and cerebral venous sinus thrombosis, given the headache’s aggravation by abrupt head movements? This would be the most critical next step before focusing further on cervicogenic or TMD-related headache.
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Subsequently I asked: “My MRI used the following techniques: séquences axiales T2, diffusion, écho de gradient, 3D FLAIR, angio-IRM. My MRI had the following conclusions: trophicité cérébrale normale; ventricules sont fins; pas de collection péricérébrale; pas de lésion parenchymateuse focale; pas de trace hémorragique; pas de lésion hyperintense en diffusion; pas d'argument en faveur d'une hypotension intracrânienne; angio-IRM: pas d'anévrisme; IRM cérébrale sans particularité. It may also be interesting to note that the headaches are usually better in the morning and worse in the evening. Also that sedatives like zolpidem can acutely eliminate the headaches.”, and he answered: “
Most Likely Diagnoses:
1. Chronic tension-type headache is less likely given the clinical picture. The International Classification of Headache Disorders (ICHD-3) and recent reviews emphasize that tension-type headache is typically not aggravated by abrupt head movements, is often responsive to NSAIDs or acetaminophen, and does not show marked diurnal variation or acute response to sedatives such as zolpidem. The lack of response to analgesics and the acute elimination of headache by sedatives are atypical.
2. Cervicogenic headache remains a strong consideration. Cervicogenic headache is often provoked by neck movement or abrupt head motion, and can present with bilateral, frontotemporal pain. However, the absence of neck pain and the bilateral nature make this diagnosis less definitive, as most reliable features include pain radiating from the neck and provocation by neck movement.
3. Temporomandibular disorder (TMD)-related headache is plausible, given the history of jaw surgery, ongoing malocclusion, and the known association between TMD and headache. TMD can present with bilateral, frontotemporal pain and may be exacerbated by jaw movement or malocclusion.
4. Sedative-responsive headache suggests a functional or psychogenic component, as acute elimination by zolpidem is not typical for primary headache disorders. This may indicate a somatoform or tension-related headache with prominent central sensitization.
Most Important Not to Miss Diagnoses:
1. Cervical artery dissection is unlikely given normal MRA findings, as recommended by the American Heart Association.
2. Intracranial mass or posterior fossa lesion is excluded by normal MRI, including advanced sequences.
3. Idiopathic intracranial hypertension is unlikely given normal MRI findings and absence of papilledema or other signs of raised intracranial pressure.
In summary, the clinical picture does not strongly support tension-type headache. The most likely causes are cervicogenic headache, TMD-related headache, or a functional/sedative-responsive headache, with critical secondary causes effectively ruled out by imaging and clinical features.
“.
Subsequently I asked OpenEvidence: "Shaking my head stimulates the headaches, and maybe unilaterally at times to my right side only.", and he answered: "
Yes, shaking the head can stimulate headaches that are sometimes unilateral, specifically affecting only the right side, in a patient with bilateral, frontotemporal headaches that are worsened by abrupt head movements, unresponsive to nonsteroidal anti-inflammatory drugs or acetaminophen, and with a history of jaw surgery and ongoing dental malocclusion, as well as normal brain MRI findings. The most likely etiologies are cervicogenic headache and temporomandibular disorder (TMD)-related headache. Cervicogenic headache is characterized by pain provoked by neck movement, which can be unilateral or bilateral, and may radiate to the frontotemporal region. The most reliable clinical features are pain that starts in the neck and radiates to the frontotemporal area, and provocation of pain by neck movement, including abrupt or shaking movements. TMD-related headache can also present with unilateral or bilateral pain, often in the frontotemporal region, and is associated with jaw dysfunction or malocclusion.
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Subsequently I asked OpenEvidence: "Forcing my mandible backwards to try improve my occlusion creates pains at the head and TMJ joint. Is it possible I have multiple headache types simultaneously, both cervicogenic and TMD-related headaches? Maybe chronic tension headaches too? With the previous MRI I did, is it still possible I suffer from cerebral venous sinus thrombosis, and are internal jugular vein stenosis or cerebral vasculitis possibilities?", and he answered: "
Most Likely Diagnoses:
It is possible for a patient with bilateral, frontotemporal headaches worsened by abrupt head movements, unresponsive to NSAIDs or acetaminophen, and with a history of jaw surgery and ongoing dental malocclusion, to have multiple headache types simultaneously, including cervicogenic headache, temporomandibular disorder-related headache, and chronic tension-type headache. The medical literature recognizes frequent comorbidity and overlapping features among these headache types, especially in patients with musculoskeletal and dental abnormalities.
Cervicogenic headache is reliably provoked by neck movement and may be unilateral or bilateral. TMD-related headache is common in patients with jaw dysfunction and malocclusion, and pain can be triggered by mandibular manipulation. Chronic tension-type headache may coexist, particularly in those with psychosocial stressors or muscle tension. The presence of pain with forced mandibular movement strongly supports TMD involvement.
Most Important Not to Miss Diagnoses:
Cerebral venous sinus thrombosis (CVT) is unlikely given a normal brain MRI with magnetic resonance angiography (angio-IRM), but cannot be fully excluded unless dedicated MR venography (MRV) or CT venography was performed. The American Heart Association recommends MRV or CTV as the optimal tests for CVT diagnosis, as standard MRI and MRA may miss isolated cortical vein thrombosis or subtle sinus involvement. Internal jugular vein stenosis is a rare cause of headache and would require targeted venous imaging; it is not typically detected on routine brain MRI/MRA. Cerebral vasculitis is also rare and usually presents with additional neurologic deficits; diagnosis requires angiography and/or CNS tissue biopsy, as outlined by the American Heart Association and the New England Journal of Medicine.
Key Additional History and Follow-up Tests:
Clarify whether MRV or CTV was performed to definitively rule out CVT. Assess for focal neurologic deficits, papilledema, or systemic symptoms suggestive of vasculitis. Targeted venous imaging may be considered if clinical suspicion for jugular vein stenosis exists.
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Subsequently I asked OpenEvidence: "Should I also evaluate the spine for underlying structural issues such as cervical spondylosis via an orthopedic surgeon, since this can cause cervicogenic headaches?", and he answered: "
A patient with bilateral, frontotemporal headaches worsened by abrupt head movements and a history of jaw surgery and malocclusion should consider evaluation of the cervical spine for structural issues such as cervical spondylosis by an orthopedic surgeon, given the potential for cervicogenic headache, especially if clinical features and conservative treatments suggest a cervical origin.
Cervicogenic headache is frequently provoked by neck movement or sustained awkward posture, and may present as unilateral or bilateral pain radiating from the neck to the frontotemporal region. Structural cervical spine disorders, including cervical spondylosis, are established causes of cervicogenic headache, particularly in patients with limited neck range of motion, neck pain, or prior neck trauma.
Clinical diagnosis relies on criteria such as pain triggered by neck movement, pain starting in the neck and spreading to oculo-fronto-temporal areas, and may be supported by diagnostic blocks or imaging to identify structural pathology.
Referral to an orthopedic surgeon for evaluation—including assessment for cervical spondylosis—is appropriate when headache features suggest a cervical origin, especially if conservative management (physical therapy, manual therapy) has failed or if risk factors such as persistent neck pain, limited cervical range of motion, or prior neck trauma are present.
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Subsequently I asked OpenEvidence: "When I move my head without utilizing my neck joint but instead by using my hip joint, I don't experience headaches. But when I move my head by utilizing the neck joint, then this triggers headaches. Is this a clear diagnostic sign of cervicogenic headache? If sedatives help me, then radiofrequency ablation may be a great treatment for me, because sedatives might work simply by deactivating nerves like would radiofrequency ablation?", and he answered: "
Yes, headache triggered by neck joint movement but not by whole-body movement (e.g., moving the head via the hip joint) is a supportive clinical sign for cervicogenic headache, though it is not pathognomonic. The most reliable clinical features of cervicogenic headache include pain provoked by neck movement or sustained awkward posture, pain starting in the neck and radiating to the frontotemporal region, and provocation by external pressure on the posterior neck. However, these features are not unique to cervicogenic headache and may overlap with other headache types, including TMD-related headache and tension-type headache. The cervical flexion-rotation test (CFRT) has moderate diagnostic accuracy (sensitivity 83%, specificity 83%) for differentiating cervicogenic headache from migraine and other headaches.
Radiofrequency ablation for cervicogenic headache is effective only when the diagnosis is confirmed by controlled diagnostic blocks (e.g., third occipital nerve block or cervical medial branch block) that produce complete or near-complete relief of headache. In patients with confirmed C2–3 zygapophysial joint pain, RFA of the third occipital nerve achieves complete relief in approximately 88% of patients, with a median duration of relief of 297 days; relief can be reinstated by repeat neurotomy. However, RFA performed without prior diagnostic blocks or at non-validated levels (e.g., C3–6) has not demonstrated efficacy.
Coexistence of cervicogenic headache and TMD-related headache is well-documented. Adults with cervicogenic headache have significantly higher TMD prevalence, reduced jaw mobility, and lower masticatory pressure pain thresholds compared to controls. Painful TMD (pain-related and mixed TMD) is strongly associated with cervicogenic headache (odds ratio 10–12). Distinguishing between these conditions requires careful clinical assessment, including evaluation of jaw mobility, masticatory muscle tenderness, and response to diagnostic blocks.
Recommended next steps:
- Diagnostic blocks: Fluoroscopically guided controlled blocks of the third occipital nerve or C2–3 zygapophysial joint are the gold standard for confirming cervicogenic headache and identifying candidates for RFA.
- TMD evaluation: Comprehensive orofacial assessment, including jaw mobility, masticatory muscle palpation, and TMJ examination, is warranted given the history of jaw surgery and malocclusion.
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Subsequently I asked OpenEvidence: "What specialist should I see for cervicogenic headaches, diagnostic blocks, radiofrequency ablation, structural spine issues evaluation, TMD evaluation?", and he answered: "
A patient with bilateral, frontotemporal headaches worsened by abrupt head movements, unresponsive to nonsteroidal anti-inflammatory drugs or acetaminophen, a history of jaw surgery and ongoing dental malocclusion, and possible cervicogenic headache, temporomandibular disorder-related headache, and structural spine issues should be evaluated and managed by a multidisciplinary team including a neurologist/headache specialist, an orofacial pain dentist, a physical therapist, a pain medicine specialist or interventional neurologist, an orthopedic surgeon, and an oral and maxillofacial surgeon.
Neurologists or headache specialists are essential for diagnostic clarification and management of primary and secondary headache disorders, including cervicogenic headache. Pain medicine specialists or interventional neurologists are required for fluoroscopically guided diagnostic nerve blocks and radiofrequency ablation, which are definitive for cervicogenic headache when clinical features and diagnostic blocks confirm a cervical source. Orthopedic surgeons are appropriate for structural spine assessment, particularly when cervical spondylosis or other musculoskeletal abnormalities are suspected. Orofacial pain dentists and oral and maxillofacial surgeons are critical for temporomandibular disorder evaluation and management, especially in cases of persistent symptoms, malocclusion, or suspected intra-articular pathology. Physical therapists play a key role in conservative management of cervicogenic headache and TMD, focusing on manual therapy, motor control exercise, and rehabilitation.
Integrated multidisciplinary care is recommended due to the frequent overlap and comorbidity of headache and TMD, and evidence supports combination therapy and collaborative management to optimize outcomes.
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Subsequently I asked OpenEvidence: "Stress increasing my headaches aligns with the diagnosis of cervicogenic headache or TMD-related headache?", and he answered: "
The fact that stress increases headaches in this patient aligns with the diagnosis of cervicogenic headache or temporomandibular disorder-related headache, as both are influenced by psychosocial factors and often present with overlapping symptoms.
Psychosocial factors, including stress, are recognized in the medical literature as important contributors to headache frequency and severity in patients with temporomandibular disorder (TMD) and headache. Stress acts as a confounder and can exacerbate both TMD-related headache and primary headache disorders, suggesting a central mechanism that overlaps TMD and headache pathophysiology.
Both cervicogenic headache and TMD-related headache are associated with increased biopsychosocial burden, and stress is a well-established factor that can worsen symptoms in these conditions.
In summary, stress-induced worsening of headache is consistent with the current understanding of both cervicogenic headache and TMD-related headache, and should be considered in the diagnostic and therapeutic approach to patients with these overlapping conditions.
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Here is the link to the complete OpenEvidence conversation.

The neurologist Dr. Celine De Ruyck said:
Weight lifting can worsen tension headaches. Good physical exercise for tension headaches is jogging.
All headache types tend to be linked. Even if cervicogenic or TMJ headaches, there probably is a muscular tension component and thus some tension headache. Thus in general tension headache treatments can help.
We can do a scan of the cervical and doppler test.
Arthur Tainmont says:
I could keep using as said here, 300-500mg of magnesium citrate.

Subsequently I asked OpenEvidence: "The neurologist proposed to do: a cervical CT scan to contemplate cervicogenic headache and radiofrequency ablation; doppler for cerebral venous sinus thrombosis, cerebral vasculitis, jugular vein stenosis. Is this good?", and he answered: "
It is not appropriate for a neurologist to propose cervical CT or Doppler ultrasound as primary diagnostic tools for cervicogenic headache or cerebral venous sinus thrombosis in this clinical scenario; MRI and CT venography are preferred for vascular evaluation, and cervical CT may be considered only for structural assessment or interventional planning.
Cervical CT is not diagnostic for cervicogenic headache, as there are no definitive imaging criteria and abnormal findings are common in asymptomatic individuals. However, CT may be considered to evaluate structural spine issues or to guide interventional procedures such as radiofrequency ablation, particularly if MRI is contraindicated or unavailable, or if detailed bony anatomy is required for procedural planning. For cervicogenic headache, diagnosis is primarily clinical, and imaging is reserved for cases with concerning features or to rule out secondary causes.
Doppler ultrasound is not a reliable method for diagnosing cerebral venous sinus thrombosis, cerebral vasculitis, or jugular vein stenosis. The American Heart Association recommends CT venography and MR venography as the optimal tests for evaluating cerebral venous sinus thrombosis, as these modalities provide clear depiction of the cerebral venous system and are sensitive for detecting thrombus. MRI is preferred for evaluating vascular and inflammatory causes of headache, including cerebral vasculitis, due to its superior sensitivity and lack of radiation exposure.
Imaging for headache should be reserved for cases with 'red flags' or suspected secondary causes, and MRI is generally preferred over CT except in emergency settings. CT of the head and cervical spine is associated with substantial radiation exposure and should be used judiciously.
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