Migraines and tension headaches are the two most common types of primary headaches. Migraines are characterized by severe pulsating pain that is often unilateral, lasting from 2-72 hours and accompanied by symptoms like nausea, sensitivity to light and sound. Tension headaches cause non-pulsating mild to moderate bilateral pain that feels like tightness or pressure around the head. Cervicogenic headaches originate from issues in the neck muscles or structures and cause unilateral pain that increases with neck movement. Secondary headaches are caused by underlying medical conditions and can include headaches due to head trauma, vascular disorders, infections or psychiatric disorders.

1. HEADACHES AND ITS TYPES
Manual therapy
BY USMAN FAROOQ

2. Definition
 The term cervicogenic headache was first introduced by
Sjaastad et al.(1983).
 The definition of cervicogenic headache is described as
‘‘Referred pain perceived in any region of the head caused by
a primary nociceptive source in the musculoskeletal tissues
innervated by the cervical nerves.’’ (Alix,1999)
 Sources of this pain lie in the structures innervated by the
C1-C3 spinal nerves and include the : (Bogduk , 2001)
upper cervical synovial joints, ligaments
muscles of the sub-cranial spine
discogenic (C2-C3) pain-sensitive dura matter

3. DEFINITION
 A Headache or Cephalalgia is pain anywhere in the head
or neck .
• It is one of the most common locations of pain in the
body with many causes.
• Its the most common symptom of a number of different
conditions

4. MECHANISM
 The brain itself is insensitive but some intra cranial
structures have receptors for pain. These are:
• The major venous sinuses
• The arteries round the base of the brain
• The meningeal arteries and
• The dura of anterior & posterior fossae (not the
middle fossa)
• All the extra cranial tissues are pain sensitive.

5. MECHANISM
 The most important mechanism underlying
headaches are:
1. Vasodilatation
2. Traction on intra cranial structures
3. Inflammation
4. Muscles spasm
5. Referred pain and
6. Psychogenic headache

6. 1. Vascular Headache
 For the vascular headache dilatation of intra cranial
vessels is responsible for headache
 Abrupt elevation of blood pressure may cause headache.
 Vascular headache is typically throbbing in nature.
 The headache of migraine and chronic hypertension on the other hand is due to
dilatation of extra cranial arteries.

7. 2. Traction on Intracranial Structures
• In addition to distension, traction on the great vessels and dura
at the base of the brain causes headache.
• Pain is momentarily increased by sudden movement of the
head.
• Sometimes pain of this nature indicates the localisation of the
cerebral tumour.
• The value of headache as a localising sign is reduced by the
fact that the pain may be referred to another part of the head
but if unilateral it does help to indicate the side of the tumour.

8. 3. Headache due to Inflammation
• Meningeal irritation due to:
1 - Meningitis
2 -Haemorrhage or
3 -other cause
• Produces generalised headache which is increased by head
movement, coughing or straining.
• Involvement of the roots of the cranial nerves contributes to
headache by causing spasm of occipital and nuchal muscles.

9. .............
• Neck rigidity is an important sign of meningeal inflammation.
• Extra cranial inflammation usually causes more localised headache.
• Cranial arteritis is also characterised by localised throbbing pain in the head,
sometimes associated with arteritis in the other parts of the body.

10. 4. Headache due to Muscle Spasm
• This is one of the most common mechanisms of headache.
• Intensity vary from a feeling of tightness to a true aching pain.
• It may be unilateral but is usually bilateral.
• Nodular areas and points of tenderness may be palpable in the painful
muscles or along the occipital and supra orbital ridges.

11. .........
 Secondary muscle spasm may contribute to a prolonged
pain referred from other structures.
 It may also be caused by irritation of cervical nerve roots
by cervical spondylosis .

12. 5. Referred Headache
• Disease of structures in the head may cause pain referred to the cranium.
• Eye disease such as glaucoma and iritis causes frontal headache.
• Ciliary spasm induced by some errors of refraction may cause pain
• Nasal and sinus disease causes pain in the molar, nasal and frontal areas.
• Dental, aural and temporo-mandibular joint diseases may cause pain
spreading far beyond the area of primary pain.
• Pain may even be referred to the head in angina pectoris.

13. 6. Psychogenic Headache
• By far the most common cause of headache is emotional upset.
• It is often vascular or tension type but There is usually an underlying
personality defect.
• It is often a sense of pressure at the vertex or a tight band round the head,
constant day and night, and completely resistant to analgesic drugs.

14. HEADACHE CLASSIFICATION
 The INTERNATIONAL CLASSIFICATION OF HEADACHE
DISORDER(ICHD) is an in-depth Hierarchical classification
of headaches published by the International Headache
Society.
 Headaches are classified as :
 1-primary headaches
 2-secondary headaches

15. PRIMARY HEADACHES
 Primary headaches are those that exist independent from any other medical
condition.

16. PRIMARY HEADACHES
 INCLUDES MAINLY:
 Migraines
 Tension type headaches
 Cluster headaches
 Also, according to the same classification, stabbing headaches and
headaches due to cough , exertion and sexual activity (coital cephalalgia) are
classified as primary headaches

17. SECONDARY HEADACHES
 Secondary headaches are classified based on their etiology and not on their
symptoms.
 occur due to an underlying structure problem in the head or neck.

18. Part 2:
The secondary headaches
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
Part 2:
The secondary headaches
5. Headache attributed to head and/or neck trauma
6. Headache attributed to cranial or cervical vascular
disorder
7. Headache attributed to non-vascular intracranial
disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth
or other facial or cranial structures
12. Headache attributed to psychiatric disorder

19. .......
 The ICHD classification puts cranial neuralgias and other
types of neuralgia in a different category.
 According to this system, there are 19 types of
neuralgias and headaches due to different central causes
of facial pain.

20. NIH CLASSIFICATION
 It outlines five types of headache:
1-vascular
2-myogenic (muscle tension)
3-cervicogenic
4-traction
5-and inflammatory.

21. VASCULAR
 The most common type of vascular headache is
migraine.
 After migraine, the most common type of vascular
headache is the "toxic" headache produced by fever.
 Other kinds of vascular headaches include cluster
headaches,

22. MUSCULAR /MYOGENIC
 When strained or irritated neck muscles cause the pain, the headaches are
myogenic.
 (When dysfunctional or irritated spinal joints cause
the pain, the headaches are vertebrogenic.)
 Caused by trauma to the head and neck from injuries such as :
-Whiplash
-poor posture
- occupational or recreational stresses ( extended phone use and other
activities that keep the neck in awkward positions for prolonged periods).

23. .......
 mild to severe discomfort or pain
 Unilateral/sometimes bilateral
 starts in the involved muscles and spread to the temples
and possibly a combination of the ears, eyes and top of
the head.

24. ..........
 Aggravated by awkward or uncomfortable postures and
certain neck movements, like turning or bending your
neck can make the pain worse.
 The muscles around your neck may also be tight and
abnormally tender.
 Limited ROM.

25. CERVICOGENIC
 Cervicogenic headache is a syndrome characterized by
chronic hemicranial pain that is referred to the head from
either bony structures or soft tissues of the neck.
 Occurrence among females is twice that of males

26. .......
 Headaches are unilateral dominanat side headache
associated with neck pain and aggrevated by neck
movements.
 Movement stresses of the cervical spine are associated
with the headache complaint (e.g headache is worse at
the end of a day’s work at the computer screen or talking
on phone)

27. Cervicogenic Headache Diagnosis
Subjective Location of Pain Starts neck, occipital
Ipsilateral, vague, nonradicular neck/shoulder/arm
Occasional radicular symptoms
Forehead, temporal, whole, frontal, orbital
Pain Characteristics Unilateral without sideshift or Bilateral
Moderate-severe
Non-throbbing/ dull, aching
Non-lancinating
Becomes more continuous
Varying duration
Pain Increases With Neck movement
Posture
Awkward head positioning
Pressure over ipsilateral cervical/occipital area
Objective Cervical ROM Decreased PROM
Palpable Findings Tender neck muscles
Change in neck muscle properties
Pain on C2/3 facet palpation and dermatome
Response to Blockade Occipital nerves, facets, or nerve roots abolish or relieve pain
Radiologic Findings (possible) Flexion/extension abnormalities
Fracture
Congenital anomaly
Tumor/rheumatoid arthritis, not spondylosis
Neck Trauma Possible
Other Nausea, vomiting
Edema, flushing
Dizziness
Phono/photophobia
Blurred vision
Dysphagia
No effect with indomethacin, ergotamine, or sumatripan

28. Traction/inflammatory
 Traction and inflammatory headaches are symptoms of other disorders,
ranging from stroke to sinus infection. Specific types of headaches include:
 Tension headache
 Migraine
 Cluster headache
 "Brain freeze" (also known as: ice cream headache)
 Thunderclap headache
 Vascular headache
 Toxic headache

29. ........
 Coital cephalalgia (also known as: sex headache)
 Rebound headache (also called medication overuse headache, abbreviated
MOH)
 "Spinal headache" (or: post-dural puncture headaches)
 Withdrawal (caused by medication or other dependency creating substance
removal/cessation)

30. Some common headaches

31. Tension headache
 It is the most common type of primary headache.
 About 90% adults have this type of headache.
 Tension headache occur more frequently in females
than males.
 The pain can radiate from the lower back of the head,
the neck, eyes, or other muscle groups in the body.

32. ......
 CAUSES:
 Stress: (after long stressful work hours or after an exam)
 Sleep deprivation
 Uncomfortable stressful position and/or bad posture
 Irregular meal time (hunger)
 Eyestrain

33. .......
 Signs and symptoms
 Constant pressure,(squeezing).
 Bilateral
 Typically mild to moderate, but may be severe.
 Frequency and duration
 can be episodic or chronic
 Episodic TTH occurrs fewer than 15 days a month
 chronic TTH occurs 15 days or more a month for at least 6 months.


34. Tension-type headaches can last from minutes to days, months
or even years, though a typical tension headache lasts 4–6
hours.

36. Migraine
 It is the second common type of primary headache .
 Migraine is a chronic neurological disorder characterized by
recurrent moderate to severe headaches often in association with a
number of autonomic nervous system symptoms.
 It affects both children and adults. Before puberty boys and girls are
equally affected by migraine headache but after puberty females are
affected more than males.
 About 5% of men and 20% of women suffers from migraine
headache in their whole life.

37. ......
Signs and symptoms:
 unilateral
 pulsating in nature,
 lasting from 2 to 72 hours.
 Associated symptoms :
-nausea
- vomiting
-photophobia (increased sensitivity to light)
- phonophobia(increased sensitivity to sound)
 The pain is generally aggravated by physical activity.

38. Up to one-third of people with migraine headaches perceive an aura(a transient visual, sensory, language, or
motor disturbance which signals that the headache will soon occur)

40. PHASES OF MIGRAINE
 The prodrome which occurs hours or days before the headache.
 The aura which immediately precedes the headache.
 The pain phase also known as headache phase
 The postdrome the effects experienced following the end of a migraine
attack.

41. 1.Prodrome phase/premonitory phase
 symptoms :
- altered mood
- Irritability
- Depression or euphoria
- fatigue
- craving for certain food
- stiff muscles (especially in the neck)
- constipation or diarrhea
- and sensitivity to smells or noise.
 occur in 60% of those with migraines with an onset of two hours to two days
before the start of pain or the aura .
 This may occur in those with either migraine with aura or migraine without aura.

42. 2-AURA
 An aura is a transient focal neurological phenomenon that occurs before or
during the headache.
 They appear gradually over a number of minutes and generally last fewer
than 60 minutes.
 Symptoms can be visual, sensory or motor in nature and many people
experience more than one.
 Visual effects occur most frequently; they occur in up to 99% of cases and in
more than 50% of cases are not accompanied by sensory or motor effects.

43. a-VISUAL AURA
 Vision disturbances often consist of a scintillating
scotoma(an area of partial alteration in the field of vision
which flickers and may interfere with a person's ability to
read or drive.)
 These typically start near the center of vision and then
spread out to the sides with zigzagging lines .
 Usually the lines are in black and white but some people also
see colored lines.
 Some people lose part of their field of vision known as
hemianopsia while others experience blurring

44. B-Sensory aura
 Sensory aurae are the second most common type.
 They occur in 30–40% of people with auras.
 Often a feeling of pins-and-needles begins on one side in
the hand and arm and spreads to the nose-mouth area
on the same side.
 Numbness usually occurs after the tingling has passed
with a loss of position sense

45. .....
 Other symptoms of the aura phase can include:
-speech or language disturbances
-world spinning
-and less commonly motor problems(weakness)

46. 3-pain phase
 Classically the headache is unilateral, throbbing, and moderate to severe in
intensity.
 It usually comes on gradually and is aggravated by physical activity.
 In more than 40% of cases however the pain may be bilateral, and neck pain is
commonly associated.
 Bilateral pain is particularly common in those who have migraines without an
aura.
 The pain usually lasts 4 to 72 hours in adultshowever in young children
frequently lasts less than 1 hour.
 The frequency of attacks is variable, from a few in a lifetime to several a week,
with the average being about one a month.

47. .......
 The pain is frequently accompanied by nausea, vomiting,
sensitivity to light, sensitivity to sound, sensitivity to
smells, fatigue and irritability

48. 4-Postdrome
 The effects of migraine may persist for some days after
the main headache has ended; this is called the migraine
postdrome.

49. Types of migraine
1. Migraine without aura, or "common migraine"
2. Migraine with aura, or "classic migraine”
3. nonmigraine headache.,aura without headache.
4. “familial hemiplegic migraine” and” sporadic hemiplegic migraine”, (mig with
motor weakness)".
5. basilar-type migraine, ( headache and aura are accompanied by difficulty
speaking’ world spinning, ringing in ears.
6. abdominal migraine (abdominal pain, usually accompanied by nausea), and
benign paroxysmal vertigo of childhood (occasional attacks of vertigo).
7. Retinal migraine involves migraine headaches accompanied by visual
disturbances or even temporary blindness in one eye.

50. ........
1. “Complications of migraine “(headaches and/or auras that are unusually
long or unusually frequent, or associated with a seizure or brain lesion. )
2. Probable migraine describes conditions that have some characteristics of
migraines, but where there is not enough evidence to diagnose it as a
migraine with certainty
3. Chronic migraine (greater or equal to 15 days/month for longer than 3
months)

51. CLUSTER HEADACHES
 Cluster headaches are recurring bouts of excruciating unilateral headache
attacks of extreme intensity.
 The duration of typical cluster headache attack ranges from about 15 – 180
minutes.
 The onset of an attack is rapid and most often without the preliminary signs
that are characteristic in migraine.
 men are more commonly affected than women, by a ratio of 2.1:1

52. ......
 Other symptoms
 The cardinal symptoms of cluster headache attack are severe or very severe
unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes.

 If left untreated, attack frequency will range from one to 8 attacks every 24
hours.
 The headache attack is accompanied by at least one of the following autonomic
symptoms:
- ptosis (drooping eyelid),
- miosis (pupil constriction)
- conjunctival injection (redness of the conjunctiva),
- lacrimation(tearing),
- rhinorrhea (runny nose),
- and, less commonly, facial blushing, swelling, or sweating, all appearing on the
same side of the head as the pain

54. Differential Dx for HeadachesCervicogenic Migraine Cluster tension
Female : Male Ratio F > M F > M M > F F>M
Laterality Unilateral (no
sideshift)
Unilateral with
sideshift
Unilateral without
sideshift
bilateral
Location Occipital to
frontoparietal and
orbital
Frontal, orbital,
temporal,
hemicranial
Orbital, temporal Frontal,occipital,circ
umferencial
Duration Intermittent or
constant
4-72 hrs 15-180’ several times
a day
Days to weeks
Triggers Neck motion,
valsalva, pressure
over C1-3
Multiple but neck
motion not typical
Alcohol, HA occur at
predicitable times of
day
Multiple bt neck
motion not typical
Associated
Symptoms
Absent/similar to
migraine, but milder
Decreased neck
motion
Nausea, vommitting,
phono/photophobia,
visual scotoma
Autonomic sx:
tearing, rhinorreha,
ptosis, miosis, all
ipsilateral to pain
Dec appetite,photo
and phono phobia
Pharmocological
Treatment
Anesthetic block,
migraine tx,
antiepiletic drugs,
antidepressant
(serotonin and
norepinephrine
reuptake inhibitors,
NSAIDs
Typical migraine
(ergots, triptans)
Oxygen, ergots,
triptans
Simple
analgesics,muscle
relaxants,medication
s used in migrain

55. Headaches and brain tumors
 The pain can be described as dull, aching, or throbbing.
 Over time, the headaches may become more frequent,
increasing in severity, and eventually be a constant
occurrence that is not easily relieved.
 Changes in body position can make them worse,
especially when lying down.
 They can also be worsened by coughing or sneezing.

56. RED FLAGS OF BRAIN TUMOR
1-These headaches are new for you.
2- Your headaches are accompanied by other symptoms:
nausea, dizziness, vomiting,seizures, difficulty speaking, weakness in the
limbs, or problems with peripheral vision.
3- Your headaches start when you wake up in the morning.

57. .......
4-Your headaches get worse over time
5-Something just doesn't seem right

58. POST TRAUMATIC HEADACHES
 Post-traumatic headache Often occurs after head injury.
 Frequency and severity of headache usually diminishes in
6 to 12 months
 Causes
 Scar formation in scalp
 Ruptured blood vessels causing hematoma

59. thunderclap headache
 It is defined as a severe headache that
takes seconds to minutes to reach
maximum intensity.(severe and sudden).
 It can be indicative of a number of medical
problems, most importantly subarachnoid
hemorrhage, which can be life-threatening.

60. .........
 Causes:
 The most important causes are:
- subarachnoid hemorrhage
- cerebral venous sinus thrombosis and
- cervical artery dissection

61. ASSOCIATED SIGNNS AND
SYMPTOMS
 In subarachnoid hemorrhage
there may be syncope(transient
loss of consciousness), seizures
meningism (neck pain and
stiffness), visual symptoms, and
vomiting
 50–70% of people with
subarachnoid hemorrhage have
an isolated headache without
decreased level of
consciousness.
 The headache typically persists
for several days.
Cerebral venous sinus thrombosis
thrombosis of the veins of the brain,
usually causes a headache that reflects
raised intracranial pressure and is
therefore made worse by anything
that makes the pressure rise further,
such as coughing.
In most cases there are other
neurological abnormalities, such as
seizures and weakness of part of the
body, but in 15–30% the headache is
the only abnormality.

62. ASSOCIATED SIGNS AND SYMPTOMS
 Carotid artery dissection and
vertebral artery dissection, often
causes pain on the affected side of
the head or neck.
 The pain usually precedes other
problems that are caused by
impaired blood flow through the
artery into the brain; these may
include visual symptoms, weakness
of part of the body, and other
abnormalities depending on the
vessel affected
.

64. CHRONIC HEADACHES

65. MANAGEMENT OF HEADACHES

66.  Firstly, assessing for symptoms of secondary causes of headache, starting with
conditions that require immediate or urgent referral before considering less
serious secondary causes including medication over-use headache.
 Then, if a secondary cause for headache has been excluded, assessing for the
primary headache disorders, starting with tension-type headache and migraine
before considering less common disorders such as cluster headache.
 Examination for signs of secondary causes of headache should include at least:
 Measurement of blood pressure.
 Palpation of the temporal arteries, if the person is more than 50 years of age.
 A neurological examination, including fundoscopy for papilloedema.
 Referral for specialist assessment.(IF secondary headaches diagnosed)

67. -----
 If the cause of the headache cannot be diagnosed then
Ask the person to record a headache diary, and reviewing
this in a few weeks.

68. HEADACHE DIARY/SUBJECTIVE
ASSESSMENT
 Quality :
 Frequency, intensity, duration location
 unilateral, bilateral, band-like?
 does it spread?
 throbbing, stabbing, dull, pressure
Radiation :
 where does it spread?
 Onset :
 gradual,sudden(thunderclap)

69.  What are their symptoms?
 Nausea/vomiting
 photo/phonophobia
 vision changes
 fever
 stiff neck
 Confusion
 Limitations at work and home?
 Does anything relieve or aggravate symptoms?
 past medical history of headaches and :
 hypertension
 HIV
 cancer
 trauma
 recent procedures

70.  Medication
 Analgesic abuse
 Recreational drugs
 Birth control
 Family history
 migraines
 subarachnoid hemorrhage
 stroke


71.  Recent change in headaches?
 Has the patient recently started a new medication?
 Is there neck pain/shoulder pain?
 Sleep position?do it awak you at night?

72. ALSO ASK ABOUT:
 Activity prior to episode
 Medications prior or after episode
 Amount of sleep the previous night
 Emotional condition
 daily activity
 Foods consumed in the past 24 hours

73. Objective Evaluation
 Posture Assessment
 Posterior View.
 Lateral view.

74. Anterior/ Lateral View

75. Mastoid Process

76. Upper Crossed Syndrome

77. Acromian Process

78. Inferior Scapula

79.  AROM/PROM:
scapular upward rotation, shoulder flexion/ER/IR, cervical rotation, flexion,
extension, forward head posture
 Strength
 Reflexes
 Sensation
 Manual Assessment of spinal movement

80.  Soft tissue assessment of muscle tightness
 myofascial trigger points.

81. type of headache probability of trigger points
1-migrain high
2-TTH Very high
3-Cluster Moderate to high
4-cervicogenic headaches high

82. RED FLAGS OF SERIOUS HEADACHES
 New onset
headaches beginning at age 40
 mass lesion, temporal arteritis
 More SEVERE and FREQUENT headaches (worst headache ever)
mass lesion, subdural hematoma, medication overuse, post-coital headache/migraine
 SUDDEN onset (maximal at onset - no increase over time)
SAH, mass lesion (especially in the posterior fossa)
 headache ASSOCIATED with
o fever (meningitis, encephalitis, systemic infection)
o projectile vomiting
o impaired mental status
o focal neurological signs - weakness, paresthesia (mass lesion, stroke)
o recent head injury
o papilledema (mass lesion, pseudotumor, meningitis)

83. treatment
 TTH:
 over-the-counter medications, including:
-Aspirin
-Ibuprofen (Advil, Motrin IB, others)
-Acetaminophen (Tylenol, others)
 In addition, alternative therapies aimed at stress
reduction may help. They include:
-Meditation
-Relaxation training
-Massage
-acupuncture
Manual therapy:
-spinal mobilization
-myofascial trigger points theray
Soft tissue mob
•Migraine
•treatment is aimed at relieving
symptoms and preventing additional
attacks.
•Avoid triggers
•. Treatment may include:
-Over-the-counter medications
-Prescription medications
-Rest in a quiet, dark room
-acupuncture
-Hot or cold compresses to your head
or neck
-Massage and small amounts of
caffeine

84. Treatment
 CLUSTER HEADACHE :
 Because the pain of a cluster headache strikes suddenly
and may subside quickly, over-the-counter pain
relievers aren't effective.
 Steps that may help include:
-Preventive medications
-Injectable medications, such as sumatriptan (Imitrex,
Sumavel Dosepro, others), for quick relief during an
attack
-Prescription triptan nasal sprays.
-Inhalation of 100 percent oxygen through a mask
-Pacing, rocking or head rubbing because most people feel
restless during a cluster headache

85. Cervicogenic Treatment Tree
Limited ROM:
Tx: Self stretches, PROM
Joint Mobility Assessment:
Central/U PAs cervical and thoracic,
downglides, OA, AA*
Tx: manips (per thoracic CPR or
qualified cervical therapist), mobs
*Test with Cervical Flexion Rotation Test (Hall
2010) and HEP of self rotation SNAGS (Hall
2007)
Soft Tissue Assessment:
 Muscle Tension or TrP (UT, levator scap,
suboccipitals, SCM, scalenes, paraspinals)
Tx: STM, ischemic
compression/suboccipital release,
stretching, e-stim
Postural Assessment:
Forward head, rounded
shoulders, or  of
thoracic kyphosis or
cervical lordosis
Tx: postural/NM re-ed,
biofeedback, pt education/
-ergonomics
Strength/Endurance
Assessment:
Deep cervical flexors,
scapular stabilizers
Tx: strengthening/endurance
TEs, NM re-ed**
** Test with Craniocervical Flexion Test
(Harris et al 2005) and possible tx of
low load cervical motor control TEs
(Jull 2002)
If Any Radicular Like Symptoms:
Assess for Radiculopathy CPR,
nerve tension tests, and/or TrP
(ie: SCM, scalenes)
Further Pain Management:
- Pt education for fear avoidance
- Refer out for
pharmacological/injection/behavior tx
- Possible surgical intervention