Cervical Dystonia in a Headache Population: General Medical Education (GME) Training to Standardize Screening
Ryoichi Inoue1, Kenneth Dalton3, Nawaz Hack4, Virginia Baker2
1U.S.Naval Hospital Yokosuka, 2Department of Neurology, U.S.Naval Hospital Yokosuka, 3Department of Neurology, Walter Reed National Military Medical Center, 4UTRGV Institute of Neuroscience, University of Texas Rio Grande Valley
Objective:
To highlight the importance of GME training on screening for cervical dystonia in patients presenting for headaches or cervicalgia.
Background:
Cervical dystonia (CD) is a condition of involuntary overactivation of the cervical musculature resulting in abnormal head posture. Notably, comorbid headache in CD is present in up to 75% of patients. Although the prevalence of CD is reported to be quite low, underdiagnosis or misdiagnosis is common. This is likely due to the challenging physical diagnosis often requiring a movement disorder specialist, and the lack of focused training in neurology residency programs. Although CD can improve with Botulinum toxin (BT), greater than 50% of patients remain untreated.
Design/Methods:
From 2017-2020, an IRB-reviewed Quality Improvement Project was initiated by a Movement Disorder Neurologist in a GME-Residency program. Chart review was performed on all patients presenting for headache, migraine, or cervicalgia, and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was performed to assess for comorbid cervical dystonia.
Results:
During this timeframe, 6455 patients presented for headache, migraine, cervical dystonia, or cervicalgia. 306 patients were diagnosed with both cervicalgia and headache. Of those patients, 5% were ultimately diagnosed with cervical dystonia. All diagnoses of cervical dystonia were made by a Movement Disorder Neurologist or resident trained in this screening approach. All patients diagnosed with cervical dystonia had chronic headaches, and most had daily headaches. Of patients diagnosed with cervical dystonia, 86% were started on treatment with BT, with a 91% success rate.
Conclusions:
Patients with cervical dystonia commonly present to Neurology for headache or migraine, as comorbid pain is frequent. Underdiagnosis of dystonia may lead to suboptimal treatment choices. Formalized training of residents to use TWSTRS on patients with headache and cervicalgia may enhance diagnosis and improve treatment outcomes.