Headaches

Question 1

What are the 3 main classifications of headaches?

Answer 1

1) Vascular
2) Inflammatory
3) Musculoskeletal

Question 2

What are vascular headaches?

Answer 2

• Migraine
• Cluster

Question 3

What are inflammatory headaches?

Answer 3

• Tumour
• Disease of eye, nose, throat
• Sinus HA
• Head trauma

Question 4

What are Musculoskeletal headaches?

Answer 4

• Tension
• Cervicogenic
• Temporomandibular dysfunction

Question 5

What is a primary headache?

Answer 5

• HA is primary concern.

Question 6

What is a Secondary headache?

Answer 6

• HA is result of complication to primary pathological process. May arise from head/neck trauma, cranial/cervical vascular disorder, or non vascular inter-cranial disorders. Drug use & withdrawal may also cause secondary HA.

Question 7

What is a migraine?

Answer 7

• Many people refer to painful HA as migraine, is actually a distinctive type of headache.
• Mechanism not completely understood. Is thought that headache is caused by vasoconstriction followed by rapid vasodilation. Some evidence suggests there may be some neurological dysfunction involved.
• Greater prevalence of migraine in women.
•Debilitating and can often interrupt work or ADL’s.
• 2 types of migraine, with aura (15%) and without aura (85%). Aura is sensory hallucination such as lights in eyes/visual disturbances, ringing in ears, or tingling in limbs or face

Question 8

What is Aura?

Answer 8

Any sensory hallucination such as lights in eyes/visual disturbances, ringing in ears, or tingling in limbs or face

Question 9

Symptoms/characteristics of migraines?

Answer 9

• Described as pulsating or throbbing unilateral pain can last 1-2 days.
• Accompanied by photophobia, phonophobia, nausea & vomiting.
• Aggravated by physical activity.
• Sufferers will generally want to lie down in dark quiet space.
• Occurrence is occasional, not daily. Some will have one or two a week.
• Sometimes preceded by aura.
• Those without aura will often have some kind of prodromal symptom such as fatigue or irritability hours to days before onset of pain.

Question 10

What is treatment for migraines?

Answer 10

• Avoid triggers
• Drugs - OTC’s are often not enough. Prescribed drugs may be prophylactic or abortive these include: Imitrex, Fiorinal, Migranal, & narcotic analgesics

Question 11

What are migraine triggers?

Answer 11

There are various triggers for migraine. Most try to avoid them as a way of controlling the frequency of occurrence.

• MSG
• Tannic foods (old cheese, red wine, chocolate)
• Coffee
•Citrus fruits

Question 12

There may also be migraine triggers associated with?

Answer 12

• Sleep loss
• Stress, or stress letdown
• Hormonal levels

Question 13

What is a cluster headache?

Answer 13

•Unrelenting cluster of HA’s of varying duration
•Affect males more than females
•Occur over weeks to months followed by periods of remission (remission could be months to years)
•May spontaneously stop
•Mechanism is unknown
•Can be confused with dental or sinus problems

Question 14

What are symptoms/characteristics of cluster headache?

Answer 14

•Severe, unrelenting, unilateral pain
•Commonly felt behind eye
•Has rapid onset that builds to peak in 10 to 15 minutes
•Lasts 15 to 180 minutes
•No aura

Question 15

Cluster HA is often associated with?

Answer 15

•conjunctival redness
•lacrimation
•nasal congestion
•visual impairment
•ptosis
•palpebral edema
•forehead/facial perspiration

Question 16

What is the treatment of cluster headache?

Answer 16

Analgesics, either OTC or prescription

Question 17

What is a hypoglycemic headache?

Answer 17

• Associated with low blood sugar – can be issue for diabetics
•Decreased blood glucose means less fuel for brain

Question 18

What is treatment for hypoglycemic headache?

Answer 18

• Eat something
➢ Eat smaller meals, more frequently
➢ Eat complex carbohydrates ‘slow food’
➢ Avoid processed carbohydrates that will cause blood sugar to spike & crash
➢ If you’re diabetic inject appropriate amount of insulin

Question 19

What is a Drug Rebound HA?

Answer 19

•May result from overmedicating - either by taking excessive doses, or taking meds when not needed
•Increasing dosages of medication are needed to control HA. (a positive feed back loop)
•Idiopathic
•May occur in those suffering from migraine, or tension HA, or chronic daily HA

Question 20

What is a Chronic Daily HA?

Answer 20

• Syndrome, not diagnosis with number of sub categories
• Categorized by patient having headache for 15+ days/ month, for at least 3 months
• Can be primary or secondary headaches
• Can be debilitating & interfere with ADL’s

Question 21

What is a Sinus HA (Inflammatory Headaches)?

Answer 21

• Pain occurs in sinus region, often infraorbital region, & upper teeth.
• Tends to worsen with forward bending, or lying down - positioning in prone may be painful.
• Caused by sinus congestion & mucosal inflammation

Question 22

What is the treatment for Sinus HA?

Answer 22

• decongestant meds, contrast compresses, nasal irrigation & steams
•Antibiotics may be used if congestion is related to bacterial infection
• Acupressure points can help with drainage

Question 23

What is a Cervicogenic (Musculoskeletal HA’s)?

Answer 23

HA as result of pain sensitive joint structures in cervical spine. Eg. facet irritation of C2-C3 can refer pain to back of head

• Will present secondarily to neck/shoulder pain
• Treating cervical impairment should decrease HA pain

Question 24

What is a Tension (Musculoskeletal HA’s)?

Answer 24

HA due to increased MRT and/or trigger points

• Will present secondarily to neck/shoulder pain & tightness
• Most common type of headache
• Increased prevalence in women
• Individual severity & duration
• Can be frequent, episodic, chronic
• If caused by trigger points, pain will be in typical referral pattern

➔ Therapists can be very effective in treating HA’s of musculoskeletal origin.
➔ Combination of Tension/ Cervicogenic HA’s is common. Chicken or egg dilemma.

Question 25

What is Etiology of Musculoskeletal HA’s?

Answer 25

• Soft tissue injury – Was there trauma that created instability, forcing muscles to tighten in order to stabilize • Overloaded musculature: faulty or dysfunctional posture - Was there postural dysfunction that led to muscle imbalances as well as joint dysfunction • Emotional tension- ongoing stress, or sudden severe stressful event • Greater occipital nerve irritation or impingement • Inflammation of joints & nerves of upper cervical spine (CN V,VII,IX,X- sensation to face, forehead, orbit, TMJ) • Cervical or thoracic joint mobility issues

Question 26

Whatever the cause there is usually a cycle of ____________.

Answer 26

Pain-->muscle contraction-->decreased circulation-->Pain

Question 27

What is the History and S/S of cervical headaches?

Answer 27

• Unilateral or Bilateral HA’s, one side is often predominant • Pain in neck or suboccipital region that spreads into head • Intensity can fluctuate between mild, moderate, or severe • Likely precipitated by stress (is common with other HA types as well)- can make headaches more frequent • May be related to trauma, Degenerative disc disease, or sedentary lifestyle & postural stresses- precipitated by sustained neck postures or movements • More prevalent in females • No familial tendency

Question 28

What are some red flags of headaches?

Answer 28

➢ Referral to physician is indicated if patient complains of any of following, as headache is probably not of musculoskeletal origin • Patient states that this is either first or worst headache they have experienced • Reports sharp pain or spikes in intensity • Change in personality or behaviour • HA worse with coughing or straining • Neurological signs and symptoms • Loss of consciousness, nose bleed • HA post head trauma

Question 29

What are Musculoskeletal impairments that may cause cervical HA’s?

Answer 29

• Joint impairments in upper cervical spine (pain & motion restriction) Upper cervical facets refer to post head & neck

Question 30

What are Facet referral pattern for cervical headaches?

Answer 30

• Poor joint alignment & biomechanics, distributes load inefficiently • Poor muscle endurance, overloading due to muscles being placed in shortened or lengthened position • Muscles of posterior neck will need to work much harder to control flexion of distal c spine • Poor shoulder girdle/scapular mobility related to muscular imbalance - ie. weak serratus anterior forces traps to overwork to upwardly rotate scapula, weak lower traps results in scapular elevation with upward rotation & causes upper traps & Levator scapula to be overactive • Impaired lumbar posture with related muscle imbalances • Impaired upper thoracic mobility • Impaired neural tissue from pressure or inflammation in upper cervical/craniovertebral region • Increased MRT • Trigger points

Question 31

What are some Trp’s referring into head?

Answer 31

➢ SCM ➢ Upper fibre traps ➢ Levator scapula ➢ Suboccipitals ➢ Temporalis ➢ Splenius cervicis ➢ Semispinalis capitis ➢ Frontalis

Question 32

What are some goals of treatment?

Answer 32

• Decrease/ Eliminate trigger points • Decrease/ Eliminate associated myofascial restrictions • Reduce or eliminate spasm (depending on the cause) • Reduce unnecessary MRT • Normalize joint mobility in cervical spine • Reduce CNS firing • Ex: Strengthen deep neck flexors (capital flexion and cervical retraction), stretch shortened structures (neck extensors) • Normalize posture/ muscle imbalances at thoracic & lumbar spine

Question 33

What are Motions of the TMJ?

Answer 33

• Depression • Elevation • Protrusion • Lateral deviation

Question 34

S/S TMJ (Temporomandibular joint) dysfunction?

Answer 34

• Pain in TMJ region that is affected by movement • Joint noise during movement • Restrictions or limitations with jaw movement • Headaches

Question 35

Potential sources of pain from TMJ (Temporomandibular joint) dysfunction?

Answer 35

• Local pain in TMJ in richly vascularized & highly innervated retrodiscal pad • Muscles of mastication • TrPs in SCM can refer into TMJ region

Question 36

Possible causes of TMJ (Temporomandibular joint) dysfunction?

Answer 36

• Poor oral hygiene • Gum chewing • Heavy kissing • Bruxism (grinding teeth excessively) • Smoking • Inflammatory conditions ie Rheumatoid arthritis • Open mouth breathing • Emotional stress • Postural dysfunction

Question 37

What is TMJ (Temporomandibular joint) dysfunction link to neck pain?

Answer 37

• Patients with neck pain respond by bruxing, which may lead to muscle or TMJ pain • Head forward posture resulting in retraction of mandible, which places anterior throat muscles in lengthened position --> increased activity in muscles that close jaw to counter mandibular depression caused by hyoid muscles • Extension of upper cervical spine places muscles & soft tissue in suboccipital region in shortened position--> increased MRT, trigger points, adhesions, mechanical pain

Question 38

Treatment goals of TMJ (Temporomandibular joint) dysfunction?

Answer 38

• Decrease unnecessary MRT, adhesions, TRP • Decrease or eliminate spasm of facial/ jaw muscles • Normalize C spine posture • Normalize joint movement at TMJ • Correct muscle imbalances in C spine/T spine/ L spine? • Patient education on relaxation techniques.

Question 39

Trigger point referrals into TMJ?

Answer 39

➢ Masseter ➢ Digastric ➢ Temporalis ➢ Lateral Pterygoid ➢ Medial Pterygoid