Headache

PT practice considerations

one of most common reasons to seek health care services
leading cause of neurology visits
can lead to decreased work capacity and social interaction
prevalence: 1/6 Americans over 3 month period 9.7% of males and 20.7% of females
highest burden of migraine age 18-44
direct and indirect socioeconomic costs ~31 billion per year

HA as a co-morbid condition

more prevalent with pts presenting with cervical complaints
comorbid neck and HA pain associated with greater HA sx severity and physical limitation in veterans
screening for HA has important implications for both tx and p

xvisceral and systemic causes of HA

stroke/TIA
hypertension
infection (ear, sinus, flu, pneumonia, etc.)
digestive disturbances
glaucoma
head injury/concussion/subdural hematoma
meningitis/encephalitis
brain tumor/aneuyrsm
kidney failure

pt history questions

how often do you get headaches?
how long does a HA episode last? (with/without tx)
have you recently noticed a change in the characteristic of your HA?
what is the intensity, location, and quality of pain?
what associated sx do you get?
what are the aggravating/relieving factors?
have you received previous tx for HA?

red flag sx

"thunderclap headache" (intense/hyperacute)
new onset HA age \>50; age

International Classification of Headache Disorders - ICHD III

HA classification committee of the International Headache Society
ICD-10 codes inclusive
first edition published in 1988
latest edition published in cephalalgia (International journal of headache) in 2018
sx-based for primary HA; etiology-based for secondary HA

important general rules

each distinct type of headache that a pt has must be separately diagnosed and coded - thus it is possible to have different types of HA coexisting
when a pt receives more than one dx, these should be listed in the order of importance to the pt
for any particular dx to be given, all listed criteria must be fulfilled

when a pt is suspected of having more than one HA type, it's helpful to have a diagnostic headache diary recording the important characteristics for each HA episode

improves dx accuracy
allows judgement of medication consumption
establishes the quantities of each of two or more different HA types or subtypes
teaches the pt to distinguish b/t different HAS

classification (ICHD-III)

part 1: primary headache disorders
part 2: secondary headache disorders
part 3: cranial neuralgias, central and primary facial pain and other headaches

part 1: primary headaches

migraine (with or without aura)
tension-type headache
cluster headache and other trigeminal autonomic cephalalgias (TAC)
other primary headaches

migraine

1.1 migraine without aura
1.2 migraine with aura
1.3 chronic migraine
1.4 complication of migraine
1.5 probable migraine
1.6 episodic syndromes associated with migraine (previously listed as childhood periodic syndrome)

1.1 migraine without aura

description: headache attacks lasting 4-72h (when untreated or unsuccessfully treated)
headache has \>/\= 2 of the following:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causes avoidance of routine physical activity
during headache \>/\= 1 of the following:
1. nausea and/or vomiting
2. photophonia and phonophobia
cannot be better accounted for by another ICDH-3

migraine in children and adolescents more often bilateral
migraine HA usually frontotemporal
occipital HA in children rare and is a red flag
in young children, photophonia and phonophobia may be inferred from behavior

1.2 migraine with aura

description: recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory, or other CNS sx usually developing gradually and followed by HA and associated migraine sx
\>/\= 1 of the following fully reversible aura sx
-visual
-sensory
-speech and/or language
-motor
-brainstem
-retinal

\>/\= 3 of the following characteristics
-at least 1 aura sx that spreads gradually \>/\= 5 mins
-two+ aura sx occur in succession
-each individual aura sx lasts 5-60 mins
-at least 1 aura sx unilateral
-aura accompanied, or followed within 60 minutes by HA

many pts with \_____________________ also have migraine w/o aura
aura usually occurs before HA but can begin after HA phase
visual aura most common (90% of pts with this classification)

2.1 tension type headache (TTH)

2.1 infrequent episodic tension-type HA
2.2 frequent episodic tension-type HA
2.3 chronic tension-type HA
2.4 probable tension type HA

TTH most common primary HA with 30-78% prevalence in general population

2.1 infrequent episodic TTH

diagnostic criteria:
a. at least 10 episodes occurring on

2.2 frequent episodic TTH

diagnostic criteria:
a. at least 10 episodes occurring 1-14 days/month for \>/\= 3 months (\>/\= 12 and

myofascial pain syndromes: upper trapezius

myofascial pain syndromes: splenius capitus

myofascial pain syndromes: suboccipital muscles

myofascial pain syndromes: masseter

myofascial pain syndromes: temporalis

2.3 chronic TTH

diagnostic criteria
a. HA occurring on \>/\= 15 day/month on average for \>3 months (\>/\= 180 days/year)
b. HA lasts hours to days or may be continuous
c. HA has \>/\= 2 of the following characteristics:
-bilateral location
-pressing/tightening (non-pulsating) quality)
-mild or moderate intensity
-not aggravated by routine physical activity
d. both of the following:
-not \>1 of photophobia, phonophobia, mild nausea
-neither moderate or severe nausea nor vomiting

3. cluster HA and other trigeminal autonomic cephalagias

3.1 cluster headache
3.2 paroxysmal hemicrania
3.3 short lasting unilateral neuralgiaform HA attacks
3.4 hemicrania continua

3.1 cluster headache

diagnostic criteria:
a. at least 5 attacks
b. severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 min if untreated
c. either or both of the following:
1. headache is accompanied by \>/\= 1 of the following:
-ipsilateral conjunctival infection and/or lacrimation
-ipsilateral nasal congestion and/or rhinorrhea
-ipsilateral eyelid oedema
-ipsilateral forehead and facial sweating
-ipsilateral miosis and/or ptosis
2. a sense of restlessness or agitation
d. attacks have a frequency from 1 every other day to 8/day

secondary headaches

another disorder known to be able to cause HA has been demonstrated
HA occurs in close temporal relation to the other disorder and/or there is other evidence of a causal relationship (i.e. brain tumor)
HA is greatly reduced or resolves w/in 3 months (shorter for some disorders) after successful tx or spontaneous remission of the causative disorder

examples of secondary HA

HA attributed to head and/or neck trauma
HA attributed to cranial or cervical vascular disorder
HA attributed to nonvascular intracranial disorder
HA attributed to a substance or its withdrawal
HA attributed to infection
HA attributed to disorder of homeostasis
HA or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
HA attributed to psychiatric disorder

11.2.1 cervicogenic headache

clinical exam findings that indicate that the pain is arising from cervical spine structures (bony, disc, soft tissue elements)
most significant physical examination findings include: dec cervical ROM (extension), + cervical flexion-rotation test (CFR)

dx criteria
clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause HA
evidence of causation demonstrated by at least 2 of the following:
-HA developed in temporal relation to onset of cervical disorder or appearance of the lesion
-HA has significantly improved or resolved in parallel with improvement in or resolution of cervical disorder or lesion
-cervical ROM reduced and HA worse by provocative maneuvers
-HA abolished following diagnostic blockade of involved structures or its nerve supply

anatomy of cervicogenic HA

fundamental mechanism is convergence
remember: when afferents from 2 parts of the body converge on same 2nd order neuron in SC, nociceptive activity along 1 afferent can be perceived as arising in the territory of the other afferent
cervicogenic HA perceived in forehead and orbit results from convergence b/t trigeminal and cervical afferents
cervicogenic HA perceived in the occiput results from convergence of b/t different cervical afferents (greater and lesser occipital nerve, etc.)

PT management: tension/cervicogenic HA

pt education
soft tissue mobilization
joint mobilization - cervical or thoracic
modalities
postural/relaxation exercise
ergonomic evaluation
stress management

spinal manipulation (SM) for chronic HA

systemic review of 9 RCTs
-included TTH, MH and CGH types
-manipulation more effective than massage for CGH and just as effective (short term) as pharmacologic tx for TTH and MH
systemic review of 6 RCTs
-SM may be effective to reduce migraine days and pain/intensity
-given limitations to studies included in this meta-analysis, results considered to be preliminary
-methodologically rigorous, large-scale RCTs are warranted

cervicogenic HA tx

upper cervical and upper thoracic manipulation v mobilization and exercise in pts with cervicogenic HA: a multi-center RCT
-6-8 sessions of upper cervical and upper thoracic manipulation were more effective than mobilization and exercise in pts with CH
-effects maintained at 3 months
combination of orthopedic manual PT and exercise is more effective in decreasing frequency and intensity of HA than "control" therapy
-short and long-term effects
-includes deep cervical flexor endurance ex, scapular retraction ex, postural education and low-load cervical flex/ext resistive ex