The International Headache Society originally classified 126 different types of headaches and orofacial pain.  In primary care 3 sub-classifications of headaches allow useful patient categorisation.

Migraine

Tension type headache

Cervicogenic headache.

Orofacial pain and Bruxism often compound the diagnosis of headache as there maybe overlapping pathophysiology. Exclusion of “red flags” is critical.

Headache “Red Flags”

1)      Instantaneous headache

2)      Sub-acute headache in patients over 55

3)      Neurological signs

4)      Fever

5)      Neck stiffness

6)      Headache worse on wakening

7)      Recent head trauma.

Having excluded the red flag categorisations you are then left with the three defining categories as above of migraine, tension type headache and cervicogenic headache.

Migraine

Symptoms …..

Fequently intense

more likely to be unilateral

Pounding

Nausea

Photophobia

Phonophobia

Helped by sleep.

Typically occurring episodes lasting between 4-72 hours.

True migraine can be managed by the use of pharmacological agents such as:

Ergotamine

Triptan

Simple analgesics

Antiemetic medications.

These are obviously issues for a prescribing physician or neurologist.  The physiotherapist needs to be aware of these therapeutic modalities as often the patient will present with neck pain which is secondary to a primary vascular cause of migraine.  Detailed history of the migraine pattern in terms of precipitating factors which maybe well known food substances e.g. chocolate, red wine, dairy products or less frequently dehydration, fatigue, exercise, physical loading, ergonomics and musculoskeletal factors.  While these patients may have true vascular migraine, mechanical factors amenable to physiotherapy may also be relevant triggers and thus are legitimate targets for treatment.

Tension-Type Headache

Very often a chronic migraineur develops a pattern, persistent tension type headache as part of an ongoing symptom pattern punctuated by episodes of an acute vascular migraine.  The ongoing tension headache is often more debilitating and functionally impairing and harder to manage with pharmacological strategies.  Typically described as:

Dull pressure

Band like pain radiating from the forehead to the occiput

Often involving the neck muscles.

Pathogenesis is unclear at this point.  In association with persistent muscle tension the obvious therapeutic strategies of optimising muscle control, improving deep neck flexor function and optimising scapula control are all part of the routine testing protocols which should be addresses if clinically demonstrated.  For patients who do not display these deficits there maybe a role for general relaxation or specific biofeedback training. The commonest clinical challenge is to prioritise from a multitude of co-existing findings.

Cervicogenic Headache

This is frequently under recognised in primary care masquerading under a diagnosis of migraine.  Typically these patients describe symptoms, which last longer than an acute migraine episode of 4-72 hours with symptoms often lasting days to weeks. Sleep does not usually influence symptoms and the pain intensity is usually of less severity that an acute migraine attack.  There may be some associated sensations of aura mimicking a migraine. These can sometimes be reproduced by cervical provocation testing using manual techniques.  Pain is usually localised on one side and frequently periorbital distribution but can also involve the maxillary and mandibular regions. Co-existing TMJ pathology may compound the diagnosis.

TMJ Related Headache

The pain referral pattern from the TMJ may involve the temporal and frontal regions and the myofascial referral zones involve the head, face and neck.  The primary issue with TMJ related pain is to establish whether it is driven by Dental issues relating to occlusion and bite mechanics, which require specific intervention from those specialties.

Alternatively, Bruxism (habitual grinding) – both nocturnal and daily are often significant perpetuating factors in the symptom pattern.  Treatments that target the TMJ involve specific joint mobilisation, improving general ranges of motion, post-isometric  relaxation, general jaw mobilisation and specific myofascial trigger point therapy using either palpatory of dry needling techniques.  Dental occlusion splints at night are also typically part of the management strategy.

From a physiotherapy perspective it is common to observe  a temporary reduction in clinical signs by treating symptomatic articular / myofascial components but the effects of treatment are relatively short lived.  In these situations the challenge is then to explore symptom drivers.  The use of kinesio tape is beneficial for evaluating the role of postural alignment as often there is a dual ergonomic and stress / tension component related to occupational factors as part of the symptomatology.  These are undoubtedly challenging patients to treat and certainly require multi disciplinary collaborative input in order to optimise management.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 5 comments | Add to del.icio.us
Post tags: cervicogenic headache, Headache, headache back of head, migraine, orofacial pain, tension headache, TMJ, TMJ disorder, tmj myofascial pain, TMJ symptoms, TMJ syndrome, types of headaches, types of migraine headache

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symptoms

behavioural characteristics

regional distribution

temporal characteristics

responsiveness to pharmacological intervention.

Many patients are diagnosed as Migraine sufferers but  do not fit the classical ” migraine with aura” classification and are then classified as “atypical migraine without aura”.

While many of these patients can identify specific triggers (alcohol, dairy products, chemical irritants, ambient lighting, fatigue and dehydration many are unable to determine triggers.

Unfortunately, many chronic migrainuers develop “Tension type headache” or alternatively “chronic daily headache”

Physiotherapists dealing with this type of caseload commonly find a multitude of clinical signs in the cervical & thoracic spine together with TMJ dysfunction.

The clinical challenge is to determine the relevance of co-existing physical signs and the prioritisation of legitimate targets to treat.

The pain producing structures may be….
Articular

Myofascial

Neural

Common mechanisms may precipitate sensitisation of these structures

Such as

postural adaptation

occupational factors

ergonomics

previous musculoskeletal history

and the clinician must prioritise the primary target tissue.

Often this is influenced by clinician bias as to whether they utilise a manual therapy approach, a general exercise regime, a specific muscle imbalance protocol, myofascial techniques or dry needling.

The direction for future research into cervicogenic headaches needs to look at the testing and interpretation of musculoskeletal clinical signs which are frequently associated with headaches in order to establish clinical prediction rules and a clinical efficacy protocol for the management of these challenging patients.

Share your experiences with fellow clinicians by adding your comments below.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post tags: cervicogenic headache, manipulation, manual therapy, migraine, physiotherapy, TMJ

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