The Yoga Teacher With a New Headache
A 34-year-old yoga instructor (teaches 12 classes/week) presents with 8 weeks of right suboccipital headache that began without trauma. She describes it as "pressure from behind the eye" and reports two episodes of brief visual blurring in the right eye in the past month. The headache is present on waking three or four mornings a week and has woken her at 3 a.m. twice. There is no nausea, no jaw pain, no arm symptoms. Cervical rotation right is DP with the familiar headache reproduced at end range; cervical rotation left FN; cervical flexion FN; cervical extension DP with a strong stretch sensation but no headache. Blood pressure today is 138/86. She asks whether "it is just the neck" and wants to carry on with her classes. She has a full SFMA booked for next week and is keen to get going.
1. Separate the findings that drive referral from those that do not, and justify each.
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Drives referral: new-onset headache in her thirties with no trauma, waking her from sleep, unilateral visual symptoms, and a frequency that appears to be increasing. A headache that changes pattern or carries cranial or visual features is not an SFMA problem and will not be solved by a breakout.
Does not drive referral on its own: the DP scores. DP means painful dysfunction; it obliges you to check referral criteria, not to automatically refer. Familiar reproduction of her headache with cervical rotation is a mechanical finding, but mechanical reproduction does not exclude serious pathology. Blood pressure 138/86 is a single reading - repeat it, do not build a decision on it. Absence of nausea, jaw pain and arm symptoms is reassuring but not decisive.
Clinical trap: do not use positional cervical tests as a clearance gate for cervical arterial dysfunction. Their sensitivity is poor, so a "negative" screen does not rule anything out; the decision rests on the headache history and the visual symptoms, which is why this goes to a medical colleague.
2. What exactly do you document and say to her today?
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Document: onset and course; frequency and night waking; the visual symptoms in her own words; that cervical rotation right reproduced her familiar headache and the score assigned; the other scores; explicitly, what you did not do (no end-range rotation or extension work, no breakout into pain); the referral made and to whom; what you told her to watch for; and the review date.
Say: "The neck findings are real - rotation reproduces your headache. But a headache that wakes you and comes with visual changes needs a medical look before we treat it as a neck problem. Nothing I found today suggests an emergency, but that is why we are checking."
Avoid both errors: "it is just your neck" dismisses findings that need work-up; "there is something wrong with your arteries" states a diagnosis you cannot make. Give the reasoning, not a label.
Plan: pause the DP breakout work that reproduces the headache, keep her teaching with pain-free ranges, and hold the scheduled SFMA until the medical picture is clarified.
3. She returns 3 weeks later with medical clearance and no visual symptoms. The headache persists but no longer wakes her. How do you proceed?
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Re-score before treating. The findings may have changed and old scores are a poor basis for a new plan.
Work in this order: if cervical rotation right is still DP, treat pain-first with pain-free breakouts - thoracic rotation, scapular mobility, suboccipital soft tissue, deep neck flexor and extensor control - and keep her out of end range. Once it converts to DN, break out properly and work the restriction with range and control work.
Use the top tier as the re-test each session: one repetition of the pattern, scored, before and after the intervention. That single habit tells you whether you picked the right driver.
Load matters: she teaches 12 classes a week, so cervical extension is a dose issue as much as a mobility issue. Graded exposure and positioning during teaching belong in the plan, not just table work.
Document the conversion, the change in headache behaviour, and the point at which medical input was sought and what came back.