Osteopathic approach to headache

Question 1

How are the c-spine vertebrae different than the rest anatomically?

Answer 1

Facet orientation, uncovertebral joints, structure of atlas and axis (think about structure and function here), bifid spinous processes, transverse processes, articular pillars

Question 2

cervical spine biomechanics review

Answer 2

OA- primary flexion extension, secondary rotation and sidebending
AA- only rotation
Rest- all 3

OA dysfunction- opposite sides, always in F or E
AA- NO sidebending or extension dysfunction! Only rotation
Cervical- Never a Neutral!!!

MET is direct, will always be in opposite of diagnosis.

Question 3

PRIMARY HEADACHE types

Answer 3

(90%)
Tension-type headache, 
Migraine, 
Cluster headache
Paroxysmal hemicrania.

Question 4

Secondary Headaches (a long list)

Answer 4

Headache due to infection
including sinusitis, otitis media, dental sepsis, meningitis, brain abscess, encephalitis, other infections
Substance induced headaches
including headache due to medication, substance abuse or substance withdrawal
Headache due to trauma and degenerative causes
including cervical spondylosis, head injury
Headache due to vascular causes
including temporal arteritis, subarachnoid hemorrhage, intracranial hemorrhage, ischemic stroke, transient ischemic attack, venous sinus thrombosis
Headache due to a disorder of homeostasis
including metabolic disturbances, hypertension, hydrocephalus, and exhaustion
Headache due to a disorder of facial or cranial structures
including refractive error, trigeminal neuralgia, temporomandibular joint syndrome , glaucoma
Headache due to non-vascular intracranial causes
including intracranial space occupying lesions, idiopathic intracranial hypertension (pseudotumor cerebri)
Headache due to a psychiatric disorder
including depression, anxiety

Question 5

HPI for headaches

Answer 5

Onset (acute, subacute/insidious, chronic, intermittent)
Quality (dull, sharp, throbbing, pulsating…)
Location
Intensity (pain scale description)
Associated symptoms (systemic, visual, auditory, vestibular, transient neurologic…)
Timing (frequency, duration)
Exacerbating/ameliorating factors
Prodromes and triggers
Any previous evaluation for similar c/o
Previous treatment (Rx or self administered)

Question 6

Family history related to headache

Answer 6

Migraine (90% have family members with migraine)
DM or HTN
Sub-arachnoid aneurysm or hemorrhage (4x increased risk)

Question 7

PMH/Surg Hx/Trauma Hx

Answer 7

Previous headache history (if so include previous work-up and interventions)
Sleep disorders
Disease processes that cause headache (vascular, rheumatologic, etc)
Cervical, cranial or facial trauma, including surgery

Question 8

Soc/ Meds

Answer 8

Legal or illegal drugs
OTC antihistamines
Rx drugs with headache side effects
Situational stress, abuse
Occupational hazards
Leisure activities

Question 9

What kind of headache is this

42 year old female with a history of chronic headache (HA), usually 3/10. Usually starts as a dull ache at the base of the head, slowly moves anteriorly to the right eye and top of head. Accompanied with nausea and abdominal pain when really painful (can get as high as 8/10).

Answer 9

Cervicogenic Cephalgia

Question 10

Nociception in the head: what does the trigeminal nerve innervate

Answer 10

Sensory Innervates
Venous sinuses
Nasal sinuses
Dural structures
Vasculature (MCA)
Skin of face and anterior scalp
Teeth
Pharynx
Parts of ear
Jaw (except angle)

Question 11

Nociception in the head: Upper cervical complex (OA, C1-C3)

Answer 11

Innervates 
Neck 
Posterior head
Posterior cranial fossa meninges
Angle of mandible

Question 12

reflex loops

Answer 12

viscero-somatic (VSR)
visero-visceral (VVR)
Somato-somatic (SSR)
Somato-visceral (SVR)

Question 13

What kind of reflex is cervicogenic headache?

Answer 13

somatovisceral reflex—the abnormal biomechanical motion (somatic dysfunction) and pain from the upper cervical spine sends nociceptive information to the upper cord via C1 and C2 (and sometimes even as low as C3) rootlets. The upper cord area gets facilitated, irritating the nucleus of cranial nerve 5 (CNV). This irritation will be perceived by the patient as pain in the area of CNV distribution-the head. This is also the mechanism for the nausea, gut pain, and heartburn associated with headache.

It is the close physical relationship and interconnectedness of the central nervous system that makes it so that symptoms that appear to be unrelated may, in fact, be related.

Question 14

Cervicogenic Cephalgia

Answer 14

A benign headache unrelated to intracranial pressure, infection, hemorrhage or infarct
Begins as a vague ache in the occipital region, base of head or top of neck and slowly spreads to involve the entire head
Associated with somatic dysfunction or spondylosis in the upper cervical region

Question 15

Discuss vomiting and headache

Answer 15

The vomiting center lies in the medulla oblongata and comprises the reticular formation and the nucleus of the tractus solitarius. When activated, motor pathways descend from this center and trigger vomiting. These efferent pathways travel within the 5th, 7th, 9th, 10th, and 12th cranial nerves to the upper gastrointestinal tract, within vagal and sympathetic nerves to the lower tract, and within spinal nerves to the diaphragm and abdominal muscles.

Question 16

What kind of headache is this?

9 year old male with a 4 year history of headaches. History is per father; vague pain, points to forehead and top of head usually. Will last for days and then wane, usually coming more in winter, spring and fall (2-3 per month) than summer (1-2 per summer).
PMH: seasonal allergies
ROS: snores, c/o stiff neck a lot, has been to the dentist several times in the last few months for tooth pain without cause found

Answer 16

Chronic Sinusitis

CNV innervates all of the sinuses (and the face)
Mucosa, bones, skin, ligaments, etc)
The sensitivity of the sinuses is through the trigeminal system
Headache
- Sphenoid get vertex headache
- Ethmoid it is between the eyes and the eyes
- The maxilla is at the alveolar ridge (teeth)

Question 17

Sinusitus and pain

Answer 17

Inflamed sinuses, from whatever source (infection, allergy, trauma, etc.) will send nociceptive information to the trigeminal nerve creating the perception of pain.
The trigeminal nucleus gets facilitated Creating the perception of chronic pain, and increased pain even with lower incoming nociceptive loads.

The facilitation can extend to affect the nuclei of CN 7 creating the sensation of tooth pain in the absence of tooth pathology. Facilitation of CN 9 and 10 create the sensation of nausea. Facilitation of the upper cervical cord will cause increased tissue texture changes (boggy, tight, ropy, warm or cool, tense, etc) and alter biomechanics of the upper cervical spine (suboccipital muscles, paraspinal mm, OA-C2)

Question 18

What kind of headache is this?

43 year old female with a 6 month history of increasing headache. Always has a dull ache (2/10) in the occipital region which increases to 10/10 pain when she does overhead work. She moved to Maine 4 years ago, has no PCP and has not seen a physician in 6 years.

PMH: weird skin lesion 6 years ago, doesn’t remember the name…needed surgery…
Unintentional 20 lb wt loss over the last 6 months…
And she has been falling a lot and running into things lately…

Answer 18

Malignant melanoma with brain mets

Question 19

pain from a tumor in the brain…

Answer 19

Brain parenchyma has no pain receptors
Increasing pressure from growing space occupying lesions press on dura
Metabolic chemicals irritate dura

Question 20

What are headache red flags that require further workup?

Answer 20

Worst" headache ever 
Change in regular headache pattern (location, duration, assoc sx, etc)
First severe headache 
Subacute worsening over days or weeks 
Abnormal neurologic examination 
Fever or unexplained systemic signs 
Vomiting that precedes headache 
Pain induced by bending, lifting, cough 
Pain that disturbs sleep or presents immediately upon awakening 
Known systemic illness 
Onset after age 55 
Pain associated with local tenderness, e.g., region of temporal artery

Question 21

Osteopathic case management of cervicogenic cephalgia

Answer 21

Pharmacological pain management
Osteopathic Manipulative Treatment
Upper cervical vertebral segments (OA, AA, C2)
Suboccipital muscles
Paraspinal muscles
Control of environmental triggers
Habitual postural patterns & postural retraining
Stress and relaxation recognition
Home stretching and strengthening exercises

Question 22

Osteopathic case management of chronic sinusitis

Answer 22

Control of environmental triggers
Pharmacological mgt (nasal steroid, LT inhibitor), Neti, Decrease exposure
Osteopathic Manipulative Treatment
To address the SD that occurs as a result of central sensitization reflexes
Upper cervical vertebral segments
Cervical soft tissue (inhibition, etc)
To address autonomics to the head (sinuses)
Upper thoracic vertebral segments
Anterior cervical fascia
Lymphatic techniques
Right sided SD of upper thoracics and ribs can affect drainage of the head and neck
Facial effleurage

Question 23

Osteopathic management of the brain tumor case

Answer 23

MRI
Neurosurgery/oncology referral
No Osteopathic Manipulative Treatment
At least not until fully evaluated