HEADACHES AND ITS TYPESManual therapy

BY USMAN FAROOQ

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, ligamentsmuscles of the sub-cranial spine

discogenic (C2-C3) pain-sensitive dura matter

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

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.

MECHANISM The most important mechanism underlying

headaches are:1. Vasodilatation2. Traction on intra cranial structures3. Inflammation4. Muscles spasm5. Referred pain and6. Psychogenic headache

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.

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.

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.

.............

• 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.

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.

......... 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 .

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.

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.

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

PRIMARY HEADACHES Primary headaches are those that exist independent from any

other medical condition.

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

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.

Part 2:The secondary headaches

©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)

Part 2:The secondary headaches

5. Headache attributed to head and/or neck trauma6. Headache attributed to cranial or cervical vascular

disorder7. Headache attributed to non-vascular intracranial

disorder8. Headache attributed to a substance or its withdrawal9. Headache attributed to infection10. 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

.......

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.

NIH CLASSIFICATION

It outlines five types of headache: 1-vascular2-myogenic (muscle tension)3-cervicogenic4-traction5-and inflammatory.

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,

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).

.......

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.

..........

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.

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

.......

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)

Cervicogenic Headache DiagnosisSubjective Location of Pain Starts neck, occipital

Ipsilateral, vague, nonradicular neck/shoulder/armOccasional radicular symptoms Forehead, temporal, whole, frontal, orbital

Pain Characteristics Unilateral without sideshift or BilateralModerate-severeNon-throbbing/ dull, achingNon-lancinatingBecomes more continuousVarying duration

Pain Increases With Neck movementPostureAwkward head positioningPressure over ipsilateral cervical/occipital area

Objective Cervical ROM Decreased PROM

Palpable Findings Tender neck musclesChange in neck muscle propertiesPain 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 abnormalitiesFractureCongenital anomalyTumor/rheumatoid arthritis, not spondylosis

Neck Trauma Possible

Other Nausea, vomitingEdema, flushingDizzinessPhono/photophobiaBlurred visionDysphagiaNo effect with indomethacin, ergotamine, or sumatripan

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

........ 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)

Some common headaches

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.

......

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

....... 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.

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

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.

......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.

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)

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.

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.

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.

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

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

.....

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

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 adults however 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.

.......

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

4-Postdrome

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

Types of migraine1. 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.

........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)

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

...... 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

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,circumferencial

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 milderDecreased 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,medications used in migrain

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.

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.

.......

4-Your headaches get worse over time5-Something just doesn't seem right

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

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.

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

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.

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

.

CHRONIC HEADACHES

MANAGEMENT OF HEADACHES

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)

-----

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.

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)

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

Medication Analgesic abuse Recreational drugs Birth control Family history migraines subarachnoid hemorrhage stroke

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?

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

Objective Evaluation

Posture Assessment Posterior View. Lateral view.

Anterior/ Lateral View

Mastoid Process

Upper Crossed Syndrome

Acromian Process

Inferior Scapula

AROM/PROM: scapular upward rotation, shoulder flexion/ER/IR, cervical rotation,

flexion, extension, forward head posture Strength Reflexes Sensation Manual Assessment of spinal movement

Soft tissue assessment of muscle tightness myofascial trigger points.

type of headache probability of trigger points

1-migrain high

2-TTH Very high

3-Cluster Moderate to high

4-cervicogenic headaches high

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 witho fever (meningitis, encephalitis, systemic infection)o projectile vomitingo impaired mental statuso focal neurological signs - weakness, paresthesia (mass lesion, stroke)o recent head injuryo papilledema (mass lesion, pseudotumor, meningitis)o meningismus (meningeal irritation)o seizureso trauma (intracranial hemorrhage, subdural/epidural hematoma, SAH)

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-acupunctureManual therapy:-spinal mobilization-myofascial trigger points theraySoft 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

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

Cervicogenic Treatment Tree

Limited ROM:Tx: Self stretches, PROMJoint 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 lordosisTx: postural/NM re-ed, biofeedback, pt education/-ergonomics

Strength/Endurance Assessment:Deep cervical flexors, scapular stabilizersTx: 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