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Flashcards in Osteopathic Approach to Head Pain Deck (27)
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1

PE components in osteopathic approach to head pain

HEENT

Neuro (including muscle strength, CNs, DTRs)

OSE (flexion, extension, traction, and compression of cervical spine)

Psychological disposition

Special tests as indicated

2

Areas of possible TART or lymphatic findings in PE for head pain

Cranial
Cervical
Upper thoracic
Upper ribs
Upper extremities
Sacrum
Posture/leg length

3

Osteopathic considerations in terms of location of head pain as well as possible sympathetic involvement

Anterior 2/3 = trigeminal n.

Posterior 1/3 = lesser occipital (C1-3), recurrent branches of IX and X

Sympathetics: T1-4

4

Epidemiology of tension headache

Mean age at onset 25-30

Peak prevalence at age 30-39

Female to male ratio 5:4

30-78% mean lifetime prevalence of tension type headache globally

5

Risk factors for tension headache and associated conditions

Likely: Stress, mental tension, emotional disturbance

Possible: poor self-rated health, inability to relax after work, sleeping few hours per night

Associated: anxiety, depression, migraine +/- aura, medication overuse headache

6

Tension HA causes

Uncertain cause; susceptibility influenced by genetic factors in epidemiological and twin studies

7

Tension HA pathogenesis proposed

Active myofascial trigger points in head, neck, and shoulder

Episodic tension-type headache: peripheral pain mechanisms likely more important

Chronic tension type headache: central pain mechanisms more likely involved

8

Clinical features of tension type HA

Bilateral, mild to moderate intensity, pressing or tightening quality (nonpulsating)

Not aggravated by routine physical activity

No N/V; may have photophobia or phonophobia but not both

May increase in frequency or duration over time

9

Difference between episodic tension HA and chronic tension HA

Episodic: HA can last 30 minutes to 7 days; infrequent with less than 10 episodes occurring on less than 1 day per month over the course of a year; or can be frequent with greater than 10 episodes on 1-14 days per month for greater than 3 months; often develops into chronic type

Chronic: episodes on more than 15 days per month on average for more than 3 months; may be continuous and unremitting, pts with chronic type more likely to seek care

10

Most common abnormal HEENT finding with tension headache

Pericranial muscle tenderness — tends to be mostly the scalp

Can also have dysfunction of frontal, temporal, masseter, pterygoid, SCM, splenius, and trapezius mm. (More likely with episodic than chronic)

11

General 5 models for tension HA tx

Behavioral: identify triggers, encourage following prescriptions, biofeedback, CBT and relaxation, counseling

Neurologic: analgesics and NSAIDs, caffiene, metaclopramide

Biomechanical: PT and acupuncture, OMT/manual therapy level 2, intra-oral appliance

Metabolic: sleep hygiene, hormonal influences, hydration

Respiratory-circulatory: hydration

12

5 models OMT for tension headache

Biomechanical: address myofascial SDs, address joint SDs with cranial, MET, Still’s, HVLA, or FPR

Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu

Neuro: address counterstrain points in cervicals, upper thoracics, upper ribs, and upper extremities; use cranial to address other SDs

Metabolic: improvement is d/t other approaches

Behavioral: exercise Rx to support tx of SDs contributing symptoms

13

One study showed that _______ (osteopathic technique) is more effective than control intervention for tension HA

MFR

14

Epidemiology of migraine

Currently about 15% of adults; 21% of US females and 10% of US males

Most common in american indian or alaska native > white > black or african american > hispanic or latino > native hawaiian or pacific islander > asian

15

Risk factors for migraine

Analgesic overuse (defined as daily or almost daily for over 1 month)

MS

Possibly oral contraceptives

16

Migraine associated conditions

Tension HA

Episodic syndromes: recurrent GI disturbance, vestibular migraine, benign paroxysmal torticollis

Migraine during pregnancy: preeclampsia, vascular dx (stroke, MI, PE, HTN, DM, smoking)

Endometriosis, obesity, depression, pain conditions, syncope, meniere’s disease

17

POUND mnemonic for migraine dx

Pulsating

4-72 hOurs duration

Unilateral

Nausea or vomiting

Disabling

[4-5 criteria = likely a migraine]

18

Precipitating factors for migraine

Menses, diet, fasting, stress, stress let-down, exertion, altered sleep, visual stimuli, odors, smoking, alcohol, caffeine withdrawal, oral contraceptives, vasodilators, change in weather

19

Differential dx for migraine

Tension HA, cervical spine dz (greater occipital neuralgia), acute cervical strain, intracranial mass, meningitis, subarachnoid hemorrhage, TIA, cluster HA, cavernous sinus thrombosis, optic neuritis, acute glaucoma, pseudotumor cerebri, SLE, cervical a. dissection, TMD, epilepsy, sinusitis

20

Migraine pathogenesis

With aura: spreading oligemia (reduced blood volume) in brain

Without aura is uncertain

No longer considered vascular based phenomena in terms of arterial constriction/dilation

Intracranial pain sensitive structures are meninges and intracranial blood vessels

May also be associated with spreading suppression of initial neuronal activation and increased occipital cortex oxygenation as well as dorsal pontine activation

21

General 5 models for migraine tx

Behavioral: bed rest, identify triggers, encourage following prescription, biofeedback, CBT and relaxation, aerobic exercise and yoga, counseling

Neuro: analgesics and NSAIDs, triptans for moderate to severe, metaclopramide, prophylactic meds like TCAs

Biomechanical: PT and accupuncture, OMT manual therapy level 2

Metabolic: sleep hygiene, hormonal influences - menstrual, hydration

Resp/circ: prophylactic meds: beta blockers, hydration

22

5 models OMT considerations for migraine

Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu

Biomechanical: address joint SDs with cranial, MET, Still’s, HVLA, or FPR

Neuro: address counterstrain points in cervicals, upper thoracic, upper ribs, upper extremities

Metabolic: improvement d/t other approaches

Behavioral: exercise Rx to support tx of SDs contributing to sxs

23

Type of headache caused by disorder of cervical spine and its component bone, joint, and/or soft tissue elements, usually but not invariable accompanied by neck pain

Cervicogenic HA

24

IHS dx of cervicogenic HA

A. Any HA fulfilling criterion C

B. Clinical and/or imaging evidence of disorder or lesion within cervical spine or soft tissues of neck known to be able to cause HA

C. Evidence of causation demonstrated by 2 of the following: developed in temporal relation to onset of cervical disorder/lesion, significantly improved or resolved with improvement in cervical disorder/lesion, cervical range of motion is reduced AND HA is made significantly worse by provocative maneuvers, abolished following diagnostic blockade of cervical structure or its nerve supply

D. Not better accounted for by another ICHD-3 dx

25

DDX for cervicogenic HA

Migraine

Tension HA

C2 neuralgia

Neck-tongue syndrome (rapid head turning causes subluxation of posterior AA and C2 spinal root compression —> neck pain, occipital pain, ipsilateral tongue sensory symptoms, onset is typically during childhood or adolescence

Occipital neuralgia

26

General 5 models tx for cervicogenic HA

Behavioral: no data; exercise Rx to enhance OMT

Neuro: pregabalin, anesthetic blockade, radiofrequency block

Biomechanical: PT and accupuncture, OMT, surgery

Metabolic: glucocorticoid injection

Resp/circ: no data, hydration

27

5 models OMT considerations for cervicogenic HA tx

Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu

Biomechanical: address joint SDs with MET, Still’s, or FPR; HVLA may irritate facilitated segments

Neurologic: address anterior and posterior counterstrain points

Metabolic: improvement d/t other approaches

Behavioral: exercise Rx