DiagnosticTree/Vertex
{
"tree_id": "vertex-headache", "region": "Vertex Headache", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Thunderclap headache",
"question": "Did the vertex headache reach maximum intensity within seconds to a minute — the worst headache of the patient's life, or like a blow to the head?",
"rationale": "Subarachnoid haemorrhage can present as sudden vertex or generalised headache. Any instantaneous-onset severe headache is an emergency until proven otherwise.",
"action": "Call emergency services immediately. Do not proceed with musculoskeletal assessment."
},
{
"id": "rf-e2",
"label": "Signs of raised intracranial pressure",
"question": "Is the vertex headache worse on waking, progressively worsening over days or weeks, or associated with vomiting, visual changes, or altered consciousness?",
"rationale": "Progressive headache with morning predominance, vomiting, or cognitive change may indicate raised ICP from an intracranial mass, venous sinus thrombosis, or hydrocephalus.",
"action": "Emergency medical referral. CT head urgently required."
},
{
"id": "rf-e3",
"label": "Meningism",
"question": "Is there neck stiffness with fever, photophobia, or a non-blanching rash?",
"rationale": "Meningitis or encephalitis must be excluded immediately. True meningism is resistance to passive cervical flexion, not just pain.",
"action": "Call emergency services immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal arteritis",
"question": "Is the patient aged 50+ with jaw claudication (pain building with chewing then easing at rest), scalp tenderness, or a non-pulsatile tender temporal or occipital artery?",
"rationale": "Temporal arteritis can produce scalp and vertex pain alongside temporal pain. Jaw claudication is pathognomonic. Same-day ESR required.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for musculoskeletal assessment."
},
{
"id": "rf-u2",
"label": "Cervical instability",
"question": "Is there a history of significant trauma to the head or neck combined with arm symptoms, gait disturbance, or headache worsened by neck loading?",
"rationale": "Cervical instability can refer pain to the vertex region. Manual therapy is contraindicated until cleared.",
"action": "Urgent spinal assessment — no manual therapy or cervical stretch until cleared."
}
]
},
"nodes": {
"agg-1": {
"type": "symptom",
"question": "Alongside the vertex headache, are there ipsilateral AUTONOMIC phenomena — profuse tearing, rhinitis (watering or blocked nose on the same side), conjunctival redness, or apparent drooping of the eyelid?",
"symptom_name": "Autonomic phenomena — tearing, rhinitis, palpebral narrowing",
"muscles_implicated": ["SCM (Sternal Division)"],
"muscles_excluded": ["Splenius Capitis"],
"clinical_rationale": "Vertex pain has only two myofascial sources in the Travell and Simons taxonomy: the SCM sternal division (bold — essential pattern) and the splenius capitis (spillover pattern). Autonomic phenomena — tearing, rhinitis, and palpebral fissure narrowing — are specific to the SCM sternal division and are not produced by any other muscle in this region. Their presence makes SCM sternal highly probable. Their absence routes directly to splenius capitis examination. This single binary question is the most efficient separator available for this two-muscle region.",
"yes": "exam-scm-sternal-1",
"no": "neck-movement-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation of the SCM sternal head — grasping the full muscle belly between thumb and forefinger from mastoid to sternum — reproduce the vertex or back-of-head pain? Does the SCM Compression Test (firmly gripping the belly while the patient swallows) resolve a concurrent sore throat?",
"exam_type": "palpation",
"landmark": "Patient supine, head rotated slightly toward the TrP side to relax the muscle. Grasp the full sternal belly in a pincer grip from the mastoid process down to the sternum, rolling it between thumb and forefinger to isolate taut bands and TrP nodules. SCM Compression Test: firmly grip the belly and ask the patient to swallow a small amount of saliva — resolution of pharyngeal pain with compression is pathognomonic of a sternal central TrP. Note palpebral fissure width: narrowing on the TrP side without miosis is a confirmatory sign. The sternal division refers to the vertex and occiput alongside its cheek, orbit, and temple patterns.",
"positive_finding": "Reproduces vertex, occiput, or back-of-head pain. SCM Compression Test may relieve a concurrent sore throat.",
"muscles_implicated": ["SCM (Sternal Division)"],
"yes": "result-scm-sternal",
"no": "neck-movement-1"
},
"neck-movement-1": {
"type": "rom",
"question": "Is the vertex headache aggravated by neck rotation or extension — particularly turning the head to the same side, or tilting the chin upward? Is ipsilateral cervical rotation restricted at end range?",
"movement": "Cervical rotation and extension",
"direction": "aggravating",
"muscles_implicated": ["Splenius Capitis"],
"clinical_rationale": "The splenius capitis is active during ipsilateral rotation and bilateral extension of the head and neck. It is not active at rest in a balanced upright position. Aggravation with rotation toward the pain side, with chin-up postures (bird-watching, looking up at screens), or with sustained rotated-forward head positions (monitor to one side) is the primary activation pattern. Restriction of ipsilateral rotation at end range is a consistent examination finding. Chilling — cold draught on the exposed posterior neck or sleeping with the neck uncovered — is a classic precipitating factor.",
"yes": "exam-splenius-capitis-1",
"no": "result-overlap"
},
"exam-splenius-capitis-1": {
"type": "examination",
"question": "Does flat palpation through the trapezius at the splenius capitis level — at the posterior neck just caudal to the mastoid, between the trapezius and the sternocleidomastoid — reproduce the sharply localised vertex pain? Does the patient point to the vertex with a single finger?",
"exam_type": "palpation",
"landmark": "The splenius capitis attaches above to the mastoid process and adjacent occipital bone, just beneath the SCM. It lies deep to the trapezius but superficial to the semispinalis capitis. Palpate by pressing through the trapezius in the posterior neck, approximately 2–4 cm lateral to the midline at the C₁–C₃ level. The TrP typically lies near the upper attachment zone at or just below C₂. Ask the patient to report vertex pain reproduction. CAUTION: a craniad TrP near C₂ lies close to the exposed vertebral artery — injection in this zone requires expert anatomical familiarity. The craniad TrP variant refers pain to the orbit rather than the vertex — an ache inside the skull shooting through to the back of the eye.",
"positive_finding": "Focal tenderness reproducing sharply localised vertex pain — patient typically points to the crown of the head with one finger. Craniad variant: orbital or intracranial ache.",
"muscles_implicated": ["Splenius Capitis"],
"yes": "result-splenius-capitis",
"no": "result-overlap"
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM Trigger Point — Sternal Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
"notes": "The sternal division of the SCM refers to the vertex and occiput alongside its cheek, orbit, and temple patterns — vertex pain is part of a wider facial and head referral. The cardinal distinguishing features in this region are the ipsilateral autonomic phenomena: profuse tearing (often the most alarming symptom to the patient), rhinitis, and apparent ptosis via palpebral fissure narrowing without true miosis. Head tilts toward the TrP side due to pain on holding the head upright. The patient prefers to lie with a pillow supporting the sore side so the face does not bear weight. A dry tingling cough may arise from a cough TrP near the sternal attachment. Soreness may be misattributed to lymphadenopathy.",
"treatment_hint": "Pincer palpation and spray and stretch, superior to inferior. SCM Compression Test confirms sternal central TrP — pharyngeal pain resolves on gripping the belly during swallowing. Correct forward head posture — the single most important perpetuating factor. Treating sternal SCM often resolves satellite TrPs in the face, scalp, and masticatory muscles without direct treatment of those muscles.",
"also_consider": ["SCM Clavicular Division", "Upper Trapezius", "Splenius Capitis"],
"less_likely": [
{ "muscle": "Splenius Capitis", "reason": "Autonomic phenomena are present — tearing and rhinitis are specific to the SCM sternal division; splenius capitis does not produce these features" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain on swallowing resolves when the sternal belly is firmly gripped; pathognomonic of sternal central TrP",
"Profuse ipsilateral tearing — often more alarming than the pain itself; specific to the sternal division",
"Rhinitis on the TrP side — ipsilateral nasal congestion or watering without infection",
"Apparent ptosis without miosis — palpebral fissure narrowing; confirm pupils equal and reactive to exclude true Horner syndrome",
"Head tilts toward the TrP side; patient prefers to lie on the sore side with pillow supporting the face",
"Vertex referral is part of the full sternal pattern — also check for cheek, orbit, occiput, and temple components",
"Visual disturbance with strongly contrasted vertical lines (venetian blinds, window frames) — not blurred or double vision"
],
"satellite_trps": ["Zygomaticus Major", "Orbicularis Oculi", "Frontalis", "Masseter", "Temporalis"],
"landing_page_topics": [
"Sternal vs clavicular division — full symptom profiles and palpation technique",
"Horner syndrome exclusion protocol — pupils, ciliospinal reflex, enophthalmos",
"CN XI entrapment and trapezius weakness monitoring",
"Cough TrP near sternal attachment",
"Venetian blinds visual phenomenon",
"Sleep posture and pillow advice",
"Satellite TrP treatment sequence"
],
"related_pages": [
{ "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" },
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" }
]
},
"result-splenius-capitis": {
"type": "result",
"diagnosis": "Splenius Capitis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Capitis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.15 Splenius Capitis",
"notes": "The defining feature of splenius capitis TrPs is sharply localised vertex pain — the patient characteristically points to the top of the skull with a single finger. This precise pointing quality distinguishes splenius capitis from the wider, more diffuse head pain patterns of all other cervical muscles. A craniad TrP variant, located near C₂ (just caudal to the exposed vertebral artery), refers an ache inside the skull that shoots through to the back of the eye — an orbital referral that can be confused with splenius cervicis. The muscle is not active at rest in a balanced upright position — all TrP activation arises from postural stress (ipsilateral rotation, chin-up postures, sustained rotated-forward head position) or from chilling of the exposed posterior neck. There are NO autonomic phenomena — the absence of tearing, rhinitis, and palpebral narrowing is the key feature distinguishing this muscle from the SCM sternal division.",
"treatment_hint": "Spray and stretch with contralateral rotation and slight flexion. Correct sustained ipsilateral rotation postures — monitor position, reading habits, driving posture. Keep the posterior neck warm — chilling is a consistent precipitating factor; advise a scarf or collar in cold or draughty environments. Caution on injection near the craniad TrP zone (C₂ level — vertebral artery proximity).",
"also_consider": ["Upper Trapezius", "Semispinalis Capitis", "SCM Sternal Division", "Levator Scapulae"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena — tearing, rhinitis, and palpebral narrowing absent; these are specific to SCM sternal" }
],
"confirmatory": [
"Sharply localised vertex pain — patient points to the crown with a single finger; this precision distinguishes splenius capitis from all other cervical muscles",
"Palpation through the trapezius at C₁–C₃ reproduces the vertex pain",
"Cervical rotation restricted toward the involved side — consistent examination finding",
"Aggravated by ipsilateral rotation and chin-up postures — not active at rest",
"Chilling of the posterior neck precipitates or worsens the headache",
"Craniad TrP variant: orbital referral rather than vertex — ache inside the skull shooting to the back of the eye; near C₂ level",
"NO autonomic phenomena — absence of tearing, rhinitis, and palpebral narrowing excludes SCM sternal division"
],
"satellite_trps": ["Semispinalis Capitis", "Upper Trapezius", "Suboccipital Group"],
"landing_page_topics": [
"Vertex referral — single-finger pointing as diagnostic sign",
"Craniad TrP variant — orbital referral and vertebral artery proximity caution",
"Rotation restriction — examination and interpretation",
"Chilling as precipitating factor — neck warmth advice",
"Sustained ipsilateral rotation postures — workstation and driving correction",
"Differential from splenius cervicis — vertex vs intracranial/orbital distinction"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Splenius Cervicis TrP →", "page": "Muscle:Splenius_Cervicis" },
{ "label": "Semispinalis Capitis →", "page": "Muscle:Semispinalis_Capitis" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Vertex pain with negative examination of both SCM sternal and splenius capitis should prompt consideration of a non-myofascial cause, or of a multi-muscle presentation where a key TrP in an upstream muscle (upper trapezius, levator scapulae) is activating one or both as satellites. Perform a broader posterior cervical screen.",
"screen_these": [
"Upper Trapezius TrP₁ — pincer palpation anterior border; at high intensity refers over the temple toward the vertex",
"Levator Scapulae — palpation at the angle of the neck; vertex pain is an occasional spillover pattern",
"SCM sternal head — full pincer palpation with SCM Compression Test; confirm or exclude autonomic phenomena",
"Splenius capitis — deep palpation through trapezius at C₁–C₃; note cervical rotation restriction and response to neck warmth"
],
"wiki_page": "Differential:Vertex_Headache"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Tension-type Headache",
"confidence": "uncommon",
"mimics": "Pressing or tightening vertex and generalised head pain — the vertex component of bilateral tension headache overlaps with bilateral SCM sternal and splenius capitis TrP patterns",
"distinguishing_feature": "Very high probability of myofascial TrP involvement (Ch.5, Table 5.1). Pressing or tightening quality matches the steady aching of myofascial TrP pain. Pericranial muscle tenderness consistent with TrPs is the consistent finding. Systematic TrP examination should precede any diagnosis of primary tension headache.",
"action": "Systematic TrP examination of all pericranial and cervical muscles. Both muscles in this algorithm plus upper trapezius, semispinalis capitis, and levator scapulae should be screened."
},
{
"id": "bd-2",
"condition": "Idiopathic Intracranial Hypertension (Pseudotumour Cerebri)",
"confidence": "rare",
"mimics": "Progressive vertex and generalised headache — may be misattributed to myofascial pain",
"distinguishing_feature": "Headache worse on waking, worsened by Valsalva (coughing, straining, bending forward). Pulsatile tinnitus. Transient visual obscurations (brief blackouts on postural change). Papilloedema on fundoscopy. Predominantly affects young overweight women. No muscle tenderness reproducing the vertex pain.",
"action": "Fundoscopy in any patient with new vertex headache worsened by Valsalva or associated with visual symptoms. Urgent neurology referral if papilloedema confirmed."
},
{
"id": "bd-3",
"condition": "Cluster Headache",
"confidence": "rare",
"mimics": "Severe unilateral headache with ipsilateral autonomic features — overlaps with SCM sternal tearing and rhinitis in the vertex region at high intensity",
"distinguishing_feature": "Classic cluster: strictly periorbital and temporal, 15–180 minutes, clustered in bouts with complete remission between. True Horner syndrome (miosis + ptosis, not just palpebral narrowing). SCM sternal TrP autonomic phenomena: no miosis, no true ptosis, tearing and rhinitis are the dominant features, headache is chronic not episodic.",
"action": "Confirm true Horner syndrome (miosis distinguishes from SCM palpebral narrowing). Examine for SCM TrPs in all cluster patients. Refer to neurology for cluster prophylaxis."
},
{
"id": "bd-4",
"condition": "Occipital Neuralgia with Vertex Radiation",
"confidence": "rare",
"mimics": "Occipital and vertex pain with occasional orbital referral — overlaps with splenius capitis vertex referral",
"distinguishing_feature": "Paroxysmal stabbing pain with aching between attacks, radiating from occiput toward vertex and frontal regions. Greater occipital nerve entrapment by semispinalis capitis taut bands may co-exist. Moist heat relieves myofascial pain but not neuritic pain — this distinction is clinically useful. Single-finger vertex pointing is specific to splenius capitis TrPs; neuritic pain is more diffuse and scalp-distributed.",
"action": "Treat splenius capitis and semispinalis capitis TrPs first. If neuritic component persists after adequate TrP treatment, refer to neurology. Neuroablative procedures should be a last resort."
},
{
"id": "bd-5",
"condition": "Cervicogenic Headache with Vertex Component",
"confidence": "uncommon",
"mimics": "Unilateral vertex and neck pain precipitated by neck movement — overlaps with both SCM and splenius capitis patterns",
"distinguishing_feature": "Consistent unilaterality, precipitation by specific neck movements or sustained postures, associated shoulder and arm pain. Most cervicogenic headache patients have myofascial TrPs that reproduce their headache. Reduced cervical segmental mobility accompanies TrPs.",
"action": "Conservative myofascial TrP management first. Treat TrPs before attributing restriction to fibrous fixation or proceeding to invasive neuroablative treatment."
},
{
"id": "bd-6",
"condition": "Whiplash-associated Vertex Headache",
"confidence": "uncommon",
"mimics": "Post-traumatic vertex headache — splenius capitis is one of the most commonly activated TrPs in motor vehicle accidents",
"distinguishing_feature": "History of trauma. Vertex headache following whiplash is clinically indistinguishable from primary splenius capitis TrP pain — the mechanism is the same (acute overload activating TrPs). Splenius capitis is identified as a commonly involved muscle regardless of impact direction.",
"action": "Systematic TrP screen with priority on splenius capitis, SCM, semispinalis capitis, and upper trapezius. Address perpetuating factors. Refer if neurological symptoms suggest brainstem or vestibular involvement."
}
]
}