Headache disorders are amongst the most prevalent neurological disorders worldwide that commonly effect people between 20-40years of age and have an array of presentations.
The headache itself can be painful and often disabling which is due to the head having a rich nerve supply (e.g. efferent from. Trigeminal, glossopharyngeal, vagus, upper 3 cervical nerves, etc) making it susceptible to many causes. Headaches may also have a psychological overlay, causing anxiety which also exacerbates the intensity of even mild pain. The vast majority of headaches are considered primary headaches. These are often have a benign prognosis, unlike secondary headaches which are caused by underlying problems or structural problems elsewhere in the head or neck.
Tension Type Headaches (TTH) are the most common typeof primary headache (not a result of another medical condition) that accounts for 90% of all headaches. The primary causative factor is prolonged contraction of cervical musculature leading to a reflex vasoconstriction of the superficial cranial vessels (which creates pain). These headaches commonly affect females, individuals prone to stress/anxiety and exposure to prolonged postures that stresses the cervical muscles. TTH is classified into Episodic (occur randomly, shorter duration, triggered by stress & anxiety, fatigue) and chronic(always present, pain intensity may change over 24 hrs, can result from anxiety or depression)
Common clinical features of a TTH:
- Steady
- Dull / tight / aching
- Non-pulsative
- Mild or moderate intensity (doesn’t inhibit activity of daily living)
- Bilateral or unilateral
- Pressing, tightening band like feeling
- Begin occipital can refer frontal
- Recurrent (often afternoon / evenings)
- Tenderness of muscles in neck, jaw & head
- Usually begins occipital then involves frontal& temporal areas.
Diagnosis can be often be made via a good clinical history but can be confused with migraine without aura (common migraine)
Cervicogenic headaches are extremely common which is associated (originates) with dysfunction of any tissue of the cervical spine(musculoskeletal or neural) therefore considered to be a secondary headache.Provocation of cervical structures, movement or sustained posture can reproduce the headache.
The interrelationship between the upper cervical sensory nerves that supple the upper trapezius and sternocleidomastoid (SCM) muscles, explain the neurological connections that underly the referral patterns into the head and face. Trigger points in these muscles can directly produce headaches due to its connections
Common clinical features of a cervicogenic headache:
- Starts suboccipital- parietal, vertex andretro-orbital region (Can radiate around the head)
- Unilateral pain
- Dull nagging quality
- Can last up to 6 hrs
- Can wake up in the morning with headache if cervical dysfunction aggravated by sleeping position
- Otherwise normally worsens as day progresses
- Reproduction of pain through palpation of neck and head
- Most common origin of cervicogenic headache is dysfunction in the facet joints of OA and AA with pain referral to the head
Treatment
- Manual therapy addressing cervical and thoracic regions (soft tissue massage, HVLA, e.g.)
- Improve posture (strengthening neck flexors, scapulo thoracic, etc)
- Reduction in sympathetic output
Migraines (Migraine without aura) are the commonest subtype characterised by moderate to severe headache that can be caused by a number of different biological mechanisms and environmental factors. The environmental factors can be identified as “triggers” that do vary from person to person. However, there are a number of common triggers to look out for(utilising a migraine diary can also be helpful to narrow this down):
- Stress
- Muscular tension
- Certain foods
- Hunger (missing a meal) or dehydration
- Medication
- Frequent alcohol consumption
- Caffeine
- Lack of sleep
- Hormonal changes
- Exercise
Typical Clinical Features of Migraine
- Recurrent
- Attacks last 4-72 hrs
- Unilateral location
- Moderate or severe intensity
- Aggravated by physical activity
- Often associates with:
o Nausea
o Malaise
o Photophobia (Sensitivity to light)
o Phonophobia (Sensitivity to sound)
Treatment
- Allopathic- preventative medication (Triptans)
- Manual therapy: Massage & lymphatic drainage, sympathetic relaxation, treatment of the upper thoracic, cervical spine & TMJ.
What can I do?
Understanding why you are experiencing and what type of headaches you are experiencing is important. Headaches rarely need more than a good history and physical examination for a diagnosis however further investigations may be needed in some cases.
Once a clear diagnosis has been determined appropriate treatment methods will be used to help reduce intensity and duration of symptoms. This will be achieved via various muscles and joints techniques, help improve posture and dysfunctions, improve lymphatic drainage and reduce sympathetic output.
Addressing lifestyle factors (known triggers, worker gonomics, diet, rest, exercise, etc) will also be important to help prevent future headaches
