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Headaches and

CervicogenicHeadaches

OOAApril 29, 2017

Leslie Ching, DO

Learning Objectives

At the end of this presentation, the attendee will be able to: Identify major distinguishing

characteristics of the primary types of headaches List specific anatomic areas amenable

to osteopathic treatment for headaches Discuss the role of the trigeminal nerve

in headaches Define the range of headaches for

which osteopathic treatment can be beneficial Describe how osteopathic treatment

may affect specific aspects of headaches.

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Case

A 34 year old female presents to the urgent care with a “really bad” headache. States that it started 4 days ago and without any inciting incident that she is aware of. Describes it as “all over” her head and cannot say that one area is worse than another. Denies vision changes but does say she sees little dots in her field of vision when she stands up. Denies vomiting but is having some nausea. Occasionally has mild photophobia but no phonophobia. Doesn’t feel like the headache is getting better or worse.

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Case Continued

She states that she just had a baby 3 weeks ago and is not getting much sleep. She is getting up to nurse every 1-2 hours. Sometimes she will fall asleep while nursing baby in sitting position. On further questioning, she states that her neck has been hurting. Denies numbness/tingling or radiation of pain down her arms.

No other associated symptoms.

Previous history of occasional headaches with stress.

No history of MVA, concussions, or other trauma.

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Case Continued

PE

Gen: AOx3, VSS, no acute distress

HEENT: wnl

Heart: RRR, nml S1, S2

Lungs: B/L CTA

Neuro: CN II-XII wnl, DTRs/sensation/distal motor strength intact, neg cerebellar testing

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Case Continued

Key Osteopathic Exam Findings

Decreased CRI/PRM

OAESlRr

C2-4FSrRr

Moderate cervical paraspinal muscle hypertonicity

T1-4FSlRl

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Headache Red Flags

Sudden onset of first severe HA (‘thunderclap’)

Worst HA of life

Late onset (after 30 yo) of new HA

HA associated with fever, rash, or stiff neck

Progressively worsening HA

HA associated with neuro signs/sx other than aura

HA associated with mental status changes

HA associated with exertion, sexual activity, coughing, or sneezing

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How Would You Classify Her Headaches?

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Primary Headaches

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International Headache Society

Publishes “Cephalgia,” a well respected international journal.

They define three main types of “PRIMARY” headaches

No red flags and other pathologies ruled out

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Characteristics of Migraines Migraine without aura must have at least 5

attacks with the following:

Lasts 4-72 hours

At least two of the following:

Unilateral

Pulsating quality

Moderate/severe intensity

Aggravated by physical activity (walking)

During the headache, at least one occurs:

Nausea and vomiting

Photophobia and phonophobia

POUND mnemonic: pulsatile, duration of 4-72 hrs, unilateral, n/v, disabling intensity (4/5 is most likely migraine)

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Migraines May Also Be WITH AURAS

Can involve visual, sensory, motor, or speech changes

Examples: parallel zigzag lines, ipsilateral arm or periorbital numbness or tingling, mild dysphagia

They need to be fully reversible symptoms

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Characteristics of Tension Type Headaches

Can be severe enough to be called ‘migraines’ by laypeople

Minimal neurological sx, no neurological signs—from muscle tension

Can be episodic (now and then) or chronic (constant)-most common type of HA

HA last for 30 minutes-7 days, with at least 2 of the following Pressing or tightening (nonpulsating)—“band-like

tension” Mild/moderate intensity Bilateral No aggravation by routine physical activity

One of the following: No nausea or vomiting Neither or either photophobia or phonophobia

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Characteristics of Cluster/Trigeminal HA

Rare

At least 5 attacks with following: Severe unilateral orbital or supraorbital pain lasting 15-

180 minutes (shorter episodes than tension or migraines) HA associated with at least one of the following

ipsilateral signs Conjunctival injection Lacrimation Nasal congestion Miosis, ptosis Eye edema Forehead/facial sweating Sense of restlessness or agitation Frequency from every other day to 8 times a day

May be seasonal or throughout year

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4th Category: Other Primary Headaches

Primary Cough Headache

Primary Exertional Headache

Primary Headache associated with sexual activity

Hypnic headache

Primary Thunderclap Headache

Hemicrania Continua

New daily-persistent headache (NDPH)

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Secondary Headaches

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Secondary Headaches (IHS)

Criteria

Headache as a result of another disorder known to be able to cause headaches

Headache occurs in close timing to the other disorder and/or there is evidence of a causal relationship

Headache that is greatly reduced or resolves within 3 months (or less) after successful treatment or spontaneous remission of the causative disorder.

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Types of Secondary Headaches

Secondary to:

head and/or neck trauma

cranial or cervical vascular disorder

non-vascular intracranial disorder

a substance or its withdrawal

infection

a disorder of homeostasis

to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

psychiatric disorders

cranial neuralgia

Occipital neuralgia

Trigeminal neuralgia

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CervicogenicHeadaches

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Definition

Practically speaking, a cervicogenic HA is a HA caused by something going on in the neck (patient may or may not report pain in the neck)

In the medical literature, there are clinical criteria and interventional diagnosis criteria Clinical (not completely agreed upon): U/L HA,

signs/sx of neck involvement, episodes of varying intensity or duration, moderate/nonexcruciatingpain, pain starting in neck and spreading to oculo-fronto-temporal areas May have various other sx, including n/v,

dizziness, photophobia/ phonophobia/blurred vision in IL eye, autonomic signs/sx Cervicogenic vertigo—improper input to

proprioceptive neck muscles Similar to some post concussion sx

Interventional diagnosis (impractical to do for everybody with neck pain and headaches!): nerve blocks under fluoroscopy to determine what structures are causing pain Especially AA, C2-3 (70% of cases), and C3-4

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Example of a Common Mechanism of CervicogenicHA

Increased suboccipital tension by studying and keeping your head at a certain angle

The greater & lesser occipital nerves can be entrapped by increased muscular and fascial tension as they pass through the suboccipital triangle

Chronic muscle spasm can also lead to decreased arterial blood flow—which can lead to relative ischemic muscle pain—and decreased venous outflow because of pressure on veins

…Therefore, your ‘tension headache’ is caused by, at minimum, a combination of tense muscles and fascia, impinged nerves, and decreased blood flow (arterial and venous)

By IHS Criteria, a secondary HA

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Etiologies

Circulatory considerations Lymphatic congestion (e.g., neck pain and

HA with URI)

Muscle tension, trigger points Many of the small suboccipital muscles also

act as proprioceptors for the head Myodural bridge

Irritation of joint capsules and other soft tissue structures

Bones (facets)

Nerves Occipital neuralgia

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Circulatory Issues

Any impediment to flow of blood (and/or lymph) can cause pain via:

Mass effect on nearby pain sensitive tissue

Compression of the periosteum

Nonoptimal arterial supply to and venous outflow of target tissue

Muscles

Impaired circulation has impact on muscles

Do chronically hypertonic muscles have better/worse circulation?

May press on blood vessels; veins have thinner walls than arteries and venous outflow may be affected

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Muscles

Reduced range of motion is indicative of cervicogenic HA

As noted above, muscle tension affects arterial and venous flow, as well as impinges on nerves and fascia

Trigger points are also very common with tension headaches

Reminder: trigger points are tender points that refer pain elsewhere

Thoroughly studied in allopathic literature (Travell)—these points are ones that are often targeted for Botox or lidocaine injections or dry needling

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Myodural Bridge

11 cadavers

Tendinous matrix inserting into rectus capitusposterior major and posterior cervical duramater in all specimens Direct connection between cervical mm and

dura

1 specimen examined for neural tissue, showed proprioceptive fibers

Scali F, et al. Histologic analysis of the rectus capitis posterior major’s myodural bridge. The Spine Journal. 2013;13:558-563. Accessed at: http://dx.doi.org/10.1016/j.spinee.2013.01.015

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Ligaments and Joint Capsules

Soft tissues can be sprained and torn

If mechanical integrity affected, this affects neck as a whole; can cause pain and instability

To rehabilitate, strengthen muscles in area and may consider prolotherapy

Prolotherapy: helps to strengthen ligaments by injecting substance (often dextrose) to irritate area and cause fibroblasts to proliferate

May also use platelets (PRP)

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Bones

Cervical facets can cause pain referral when irritated

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Interventional Assessment

Numbers indicate number of respondents indicating pain in the specified region after injection of noxious substance

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Nerves

The literature emphasizes 2 or 3 nerves as causative of cervical HAGreater Occipital

Nerve – C2

Lesser Occipital Nerve

Area innervated by C3 dorsal ramus

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Occipital Neuralgia

Paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves, or of the third occipital nerve sometimes accompanied by diminished sensation or dysesthesia in the affected area. Commonly associated with tenderness over the affected area

Must be distinguished from occipital referral of pain from the atlantoaxial or upper zygapophyseal joints or tender trigger points in the neck muscles or their insertions

One study excises the greater occipital nerve--!!. Relief for about 70% of patients but only for 244 days…

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Trigeminal Involvement

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Trigeminal Pathway

Cervical somatic dysfunction refers pain to head through the trigeminal pathway (innervates cranial and fascial structures such as cerebral blood vessels, dura mater)

Note the relationship of the trigeminal nerve, trigeminocervical nucleus, trigeminothalamic tract, and the spinal tract of the trigeminal to cervical spinal nerves.

Also thought to be involved in the pathophysiology of migraines

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Joint Pain and Trigeminal Pathway

Afferent nerves from these joints converge with trigeminal nucleus caudalis within the spinal cord

Pain signals can thus be referred to the same field in the thalamus as the head/face

Can be interpreted by patient as headache pain, but it is actually referred pain from neck

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Trigeminal Neuralgia

This is the classic HA associated with the trigeminal nerve

A unilateral disorder characterized by brief electric shock like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking and/or brushing the teeth (trigger factors) and frequently occurs spontaneously.

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Treatment of Headaches

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Types of Headaches That Can Be Improved With OMM

Migraines

Mixed headaches? Combination of migraine and tension HA characteristics

Tension-Type

Cluster/Trigeminal Type

Headaches related to head/neck trauma

Also worthwhile trying in other types—as long as pathological etiologies are ruled out—because OMM is noninvasive and not harmful (but be cautious with cervical HVLA)

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So What Can YOU do?

Three characteristics of headaches Duration The length of time each headache

endures Frequency The occurrence over hours, days,

weeks that the headache reoccurs Intensity The severity of the pain, often on a

scale of one to ten

You can, almost always, improve at least one of those parameters. Don’t promise a cure, their definition

and yours are probably very different. Ask “What changed…?”

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Contraindications

Possibility of nonbenign etiology—you are a physician first, so finish your workup!!!

E.g., vertebral or carotid artery dissection, tumor, stroke, aneurysm, etc

Acute fractures to skull or cervical vertebrae

Neoplastic bone disease in cervical spine

Acute trauma to head or neck without completed workup or established diagnosis

HVLA contraindicated also in connective tissue disorders (especially Down’s and RA)

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Treatment Modalities for Cervicogenic HA

Musculoskeletal targeted

OMM—be cautious with selecting techniques because patients can have worsening headaches with ones that are too vigorous (HVLA, improperly applied ME, etc)

Patient performed exercises

Massage

Trigger point modalities (injections, spray and stretch, dry needling, etc)

Acupuncture

Facet blocks

Botox injections

Prolotherapy

Nerve blocks

Epidural injections

Medications

Surgery—for relevant indications (peripheral neuropathy)

Newer: transcranial magnetic stimulation for migraines, transcutaneous nerve stimulation (for vagus and trigeminal nerve stimulation)

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Case Treatment

MFR and HVLA to T1-4

MFR, ME, and Still Technique to cervicals

OCMM and CV4

Moderate subjective improvement after tx

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Areas to Treat

Start with screening the upper thoracics and treat if needed

Mechanically, many cervical muscles have muscular and fascial attachments to the sternum/clavicle/upper thoracics

Sympathetics for the head/neck are also in the upper thoracics (T1-4)

Then assess the neck

Cervical Vertebrae

Anterior/Posterior cervical musculature

Suboccipital dura, OA junction

Consider sacral attachment of the dura

Fascial restrictions of circulation

Venous Sinus Drainage

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Systematic Review of RCTs on Manual Therapy of Cervicals for Cervicogenic Headaches

10 studies identified

7 studies compared spinal manipulation with alternative treatment or placebo

6/7 studies: manipulation showed statistically significant improvement in cervicogenic headaches when compared with control

Combining exercise with manipulation was more effective than either modality by itself

Conclusion: manipulation more helpful than “traditional physical therapy modalities”

Limitations: variety of techniques used, variety of controls

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Conclusion

Headaches can be caused by many different things—most important to rule out dangerous pathologies

Cervicogenic headaches are caused by a number of different structures in the neck

OMM can be helpful for many types of headaches, not just cervicogenic (even headaches from Arnold-Chiari that aren’t severe enough for surgery)

Important to ask about history of trauma and lifestyle and postural considerations especially with neck issues

Giving your patients neck exercises to do at home can be very helpful (you don’t need to see them as often and they feel like they have something to help themselves)

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References Biondi, D., Cervicogenic Headache: a Review of Diagnostic

and Treatment Strategies. JAOA 2005, Sup 2; 105: S 16-22

Bogduk, N., Govind, J., Cervicogenic Headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009; 8:959-68

Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Phys. 2013;87(10):682-687.

Hruby RJ, Fraix MP, Giusti RE. Chapter 60: CervicogenicHeadache. In: Foundations of Osteopathic Medicine, 3rd

Edition. Philadelphia, PA: Lippincott Williams and Wilkins. 201. PP 939-945.

International Headache Association Website: multiple access, January 2017

Richards TM. Chapter 25: The Patient with Chronic Pain, Headache. In: Somatic Dysfunction in Osteopathic Family Medicine. Ed: KE Nelson. Baltimore, MD: Lippincott Williams and Wilkins. 2007. PP:383-407.

The contributions of Drs. Shaw, Dyer, and Joy are gratefully acknowledged.

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Questions?

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