MISCP MCSP MMACP. Chartered Physiotherapist specialising in treating Sports & Musculoskeletal Disorders

MISCP MCSP MMACP

Chartered Physiotherapist specialising in treating Sports & Musculoskeletal Disorders

Physiotherapy

Classification of headaches

• Primary

• Pain felt in the head from a source in the head – Tension type Headache 50-80% prevelance – Migraine with or without aura 10-12%

– Chronic Daily headache 3% – Cluster 0.5%

• Secondary

• Pain felt in the head has a cause – Dissection, neoplasm

– Medication overuse – Cervicogenic headache

Headache or Migraine

• All headaches have a common anatomy

and physiology

• All headaches are mediated by the

Trigeminocervical nucleus (TCN)

• http://www.youtube.com/watch?v=8gw4z4Cf u18&feature=fvwrel

Trigeminocervical Nucleus

• Is a region of grey matter within the brainstem • It is causally continuous with the grey matter

of the spinal cord

Trigeminocervical Nucleus (afferents)

• Trigeminal nerve (cranial v) • Upper 3 cervical levels

• Facial nerve (vii)

• Glossopharyngeal nerve (ix) • Vagus nerve (x)

• All of these sources of afferents terminate on common second–order neurons in the TCN

TCN

• The TCN is the sole nociceptive nucleus of the head, throat and upper neck.

• Trigeminal nerve afferents will descend to the level of C3 and perhaps as low as C4.

• Because the opthalmic branch of the

trigeminal nerve extends the farthest into the TCN, cervical afferent stimulation is most likely to refer pain to the frontal-orbital region of

Convergence Hypothesis

• Successive symptoms experienced clinically reflect an escalating pathophysiological

“Sensitisation” process

• Tth is the early manifestation of this process • If the process continues uninterrupted

increasingly severe headache develops into “migraine”

Physiotherapy & Headache

 Which headaches require a physiotherapy assessment?

 What can physiotherapy do for headaches?

“There’s nothing wrong with her neck - her

earrings are too heavy!”

Which Headaches might a physiotherapist be able to assist with?

• Tension type headache

• Cervicogenic headache

Tension Type Headache(TTH)

 Episodic < 15 days a month

 Chronic > 15 days a month

 Headache lasts 30 minutes to 7 days

 Characterised by bilateral pressing or tightening head pain

 No significant associated symptoms

Muscle tenderness in TTH

• Tenderness of neck & shoulder are common • 20 muscles can refer pain to the head

• Myofascial trigger point

– Hyperirritable spot in a taut band of muscle

– Perpetuating factors such as injury or overload – Worsened by stress

Evidence

 100% of people with chronic TTH have TrP in suboccipital muscles

Nociceptive afferent input through

 Trigeminal nucleus  Dura (rcpmnr)

Fernandez-de-las-Penas et al “Trigger points in sub-occipital muscles & forward head position in tension type headaches” Headache 2006 46: 1264-1272

How does Physiotherapy help with

TTH?

• Education/prevention of aggravating postures • Manual therapy of trigger points

• Stretching & movement exercises

Cervicogenic Headache CeH



First diagnostic criteria in 1983



Included in HIS in 2004



Remains disputed by many neurologists

Goadsby PJ Cervicogenic headache a pain in the neck for some neurologists The Lancet 2009

Cervicogenic Headache

• Secondary headache

– Pain felt in the head from a source in the neck Usually unilateral

No defined pattern of frequency, severity or duration

Minimal associated features

May have a history of neck trauma or poor posture

Cervicogenic Headache

 _{Need evidence of a cervical spine problem}  Headache must be reproduced by

 1 awkward neck positions &/or

Neurophysiology of CeH

• “Convergence of trigeminal nerve & upper 3 cervical nerves in the trigeminocervical

Physiotherapy for CeH

 _{Thorough history taking}

 _{Assessment of neck posture, movement &}

muscle strength

 _{Manual examination of painful muscles, joints}

& nerves that may be acting as a pain source

Migraine

• 500,000 sufferers of migraine in Ireland • Migraine costs our economy €252 million

annually in sick leave & decreased productivity

• Average migraineur gets 1 attack/month • Loses 2 days from work each year

• & 4 days of decreased effectiveness each year • Not counting loss to family & social life

Causes of Migraine

 Exact cause is unknown ?trigeminal

?vascular

 _{60% is inherited}

Migraine-Is it a sensory processing

disorder?

• Migraine is primarily a disorder of sensory processing

• Information from the trigeminal field is no

stronger than normal but the reaction to it in the brainstem is significantly greater,

effectively generating pain from almost nothing.

Migraine

 Primary headache

 Disorder of the central nervous system resulting in pain & neurological symptoms

 Sensitivity of trigeminovascular system  Genetic predisposition

 Attacks normally last 4-72 hours

 Unilateral, pulsating, moderate to severe pain  Associated symptoms, nausea, photophobia,

Trigger Factors

“I have a terrible ice cream headache all the time”

Migraine Threshold

Migraine

Threshold

Threshold

• Keep a headache Diary

• Know how many triggers it takes to bring you over your migraine threshold

Migraine & the Neck

 60% of people with migraine have neck pain

 _{More prevalent than nausea}  _Options:

1 separate migraine & neck pain

2 neck pain is a symptom of migraine

Physiotherapy & Migraine

• How an individual migraine sufferer responds to physiotherapy treatment will depend on the extent to which the muscles/joints are involved

Physiotherapy for migraine with a

possible neck involvement

• Thorough history taking

– Rule out red flags, neurological examination • Assess posture, neck movement & strength

• Manual examination of muscles joints & nerves that may be acting as pain source

Clues to neck involvement with

migraine

• Neck pain

• Previous trauma to the neck

• Poor postures at work or home

• Awkward neck posture or movement bring on migraine

• Pressure to back of neck, massage, heat relieving headache

Positive signs on neck examination



Reproduction & resolution of headache

on palpation of upper cervical spine



Stiffness & tenderness of joints or

muscles with poor posture

O-C1

C1-C2

C2-C3

Treatment of neck related migraine

• Sustained joint mobilisation techniques • Muscle release - triggerpoint release &

stretching

• Posture re-education/ ergonomics • Specific muscle strengthening

Has physiotherapy been proven to

work for headaches

• 2 studies have been done in Australia showing that physiotherapy helps cervicogenic

How effective has physiotherapy

been in the treatment of migraine?

• No research published to date

• On going audit of patients attending Beaumont Hospital

Audit of Physiotherapist role in

Beaumont Migraine Clinic

• 68 people referred by the team to Julie Sugrue • Of these 66% had findings of cervical spine

dysfunction & physiotherapy was advised • Examination findings included

– Reproduction of a familiar head pain (69%) – Myofascial trigger points (87%)

Audit of Physiotherapist role in

Beaumont Migraine Clinic

• Out of patients followed up in Beaumont Hospital

• Average 4 sessions

• Frequency reduced from 30 to 2 days/month • Intensity reduced from 8/10 to 3/10

Audit of Physiotherapist role in

Beaumont Migraine Clinic

• None of the people had a diagnosis of cervicogenic headache

– Migraine without aura

– Mixed (migraine and other headache) – Tension type headache

Treatment

• Detailed history of pattern, severity, frequency of headaches

– Rule out red flags

• Examine the neck by palpation

• Reproduction & easing of familiar migraine pain on palpation

Case History

 Female 57 years

 _{Right sided migraine since age 15, eye symptoms}

is indicative of impending migraine

 At least 1 migraine/ week for last few years

 When bad nausea & vomiting

 Head never clear in last 2 years (pressure in head every morning)

Case History cont

• Drug treatment 2x Solpadeine & naproxyn at first onset or Zomig

• Beaumont: Sibelium x1 initially & then up to 2/day (side effects)

• VAS never 0, varies from 5 up to 10 if doesn’t get meds in time.

Examination

• Head forward posture • Limited cervical flexion

• Mild scoliosis convex left upper T spine • Poor scap position

• Doesn’t open mouth much when speaking

• Reproduction & lessening of familiar pain with palpation of upper cervical spine

Treatment

• Posture correction

• Advice re pillows & sleeping position • Manual therapy

• Exercises for neck ROM and low level strengthening exercises

Progress

_{Some short periods of head clear after first}

treatment

_{After 3 treatments had longer gap between}

migraines

Took 6 treatments before significant decrease in frequency of migraines

now no Sibelium, migraines about 1/month managed with solpadeine, head clear

Case History 2

 Nurse in her 40’s

 Left sided migraine with her period since aged 14, lasting 2-3 days & can be from 3-7/10 on a pain scale,

 _{Right sided migraine started 5 years ago,}

monthly but not with cycle, can be up to 10, can cause her to miss work, worse if tired or stressed.

Headache Diary

Identify her triggers: • Night duty

• A run of long days • ½ glass of wine

• Loud music

• 20 minutes horse riding with head turned to right talking to friend

6 Month Progress

 Decreased intake of Zomig

 Decreased frequency, severity & duration of migraines

Outcomes

Physiotherapy treatment should be making a difference to either the frequency, duration or intensity of the migraine with 3-4 treatments

_{If not improving any of these then}

physiotherapy not likely to help

_{May need 6-8 treatments but should get long}

“Can you imagine what it would have been like if I hadn’t faked headaches”

Headache Summary

• Research suggests that headache & migraine is a common process sharing a common

disorder that is a sensitised TCN/brainstem • It is reasonable & logical that upper cervical

dysfunction has the potential to sensitise the brainstem

• The trigeminocervical nucleus

(TCN)/brainstem is the doorstep of the final common pathway of all headache & migraine information.

In summary

• Use the information from the migraine association www.migraine.ie

• Improve your palpation skills of the upper cervical spine.

• Look out for courses, very few

– Dean Watson