HeadachesStudy Group
Laura Maidment
Primary headaches1) Migraine2) Tension –type headaches3) Cluster headaches4) Other primary headaches
Secondary headaches Caused by another disorderIncludes cervicogenic headache
Headache classification (According to IHS, 2004)
Ranked 19 by the WHO among all diseases worldwide causing disability
Thought to be a neurovascular pain syndrome
Triggers include: red wine, skipping meals, excessive afferent stimuli, stress, hormonal changes, sleep depreviation
Two major sub-types:1) Migraine without aura2) Migraine with aura
Migraine
Recurrent headache disorder manifesting in attacks lasting 4-72 hours
Unilateral location, Pulsating quality Moderate or severe pain intensity Agg by routine physical activity eg walking During HA one of the following:1) Nausea and or/vomitting2) Photophobia and phonophobia
Migraine without aura
Recurrent disorder manifesting in attacks of reversible focal neurological symptoms (develop 5-20mins, <60mins)
Aura consisting of one of the following:1) Visual symptoms2) Sensory symptoms 3) Dysphasic speech disturbance Headache with features of migraine without
aura usually follows aura symptoms
Migraine with aura
Elimination of triggers Stress coping strategies Mild attacks: NSAID’s or acetaminophen Mild analgesics containing opoids, caffeine
are helpful for infrequent attacks (can be overused)
Severe attacks: Triptans (specifically block the release of vasoactive neuropeptides that trigger migraine pain)
Preventative: Amytriptyline
Treatment
Very common but little research Can be episodic or chronic Mild generalised pain Does not worsen with activity No nausea or vomiting Exact mechanism unknown
Tension –type headaches
Episodes of headache lasting minutes to days
Bilateral location (usually occipital/frontal region)
Pressing or tightening in quality Mild to moderate intensity May have photophobia or phonophobia Typically start hours after wakening and
worsen as day progresses
Episodic tension-type headache
Headache occuring on >15days per month on average for >3months
Headache lasts hours or may be continuous Bilateral location (usually occipital or frontal
region) Pressing/tightening quality Mild or moderate intensity May have photophobia or phonophobia
Chronic tension-type headache
Analgesics eg asprin Preventative: Amitriptyline Relaxation and stress management Manual therapy
Treatment
Usually affects men, typically at age of 20-40 Vascular headache- causing dilation of blood
vessels which creates pressure on trigeminal nerve Hypothalamus involvement Severe unilateral orbital, supraorbital or temporal
pain Lasts 15-180 mins Occurs from one every other day up to 8 times a
day Ipsilateral autonomic symptoms: nasal congestions,
rhionrrhea, lacrimation, facial flushing, horners syndrome
Cluster headaches
For attacks: triptans Long term: Verapamill, lithium Frequent, severe attacks: Prednisone(used
to treat inflammatory diseases),Greater occipital nerve block
Treatment
The pathogenesis of these headaches is still poorly understood
Thunderclap headaches: high intensity headache, <1min
Stabbing headache: ice prick pains, jabs and jolts
Cough headache: precipitated by coughing or straining 1sec-30mins
Exertional headache: Precipitating any form of exercise, 5mins-48 hours
Other primary headaches
Another disorder known to be able to cause headache has been demonstrated
HA greatly reduced after successful treatment or spontaneous remission of the causative disorder
Secondary headaches
HA attributed to head or neck trauma HA attributed to cranial or cervical vascular
disorder eg TIA, haemorrage, arteritis HA attributed to non-vascular intracranial
disorders eg intracranial neoplasm, high CSF, epileptic seizure
HA attributed to substance or its withdrawal eg acute substance overuse, medication overuse
HA attributed to infection eg intracranial, systemic, HIV/Aids
Types of secondary headaches
HA attributed to disorder of homoeostasis eg hypoxia, hypertension, hypothyroidism, fasting
HA attributed to disorder of cranium, neck, eyes, ear, nose, sinus, teeth, jaw, mouth eg Cervicogenic HA
HA attributed to disorder of cranial bone
Types of secondary headaches cont.
Pain referred from a source in the neck and perceived in one or more regions of the head or face
Precipitation of HA by:1) Neck movement or sustained awkward head
postures2) External pressure over the upper csp or
occipital region Restriction of range of motion in the neck Unilateral HA’s, originating post and
migrating to front
Cervicogenic headache
Results from a convergence of sensory input from the upper cervical spine into the trigeminal spinal nucleus
Trigeminocervical nucleus- region of upper cervical spinal cord where sensory nerve fibres in the descending tract of the trigeminal nerve interact with sensory fibres from upper cervical roots.
Cervicogenic HA mechanism
Trigeminocervical nucleus
Input from these areas can have an affect on the trigeminocervical nucleus:
1) Upper cervical facets2) Upper cervical muscles3) C2-3 IV disc4) Vertebral and internal carotid arteries5) Dura mater of the spinal cord6) Posterior cranial fossa
1) Forward head posture: increases stress on upper cervical segments
2) Decreases in active ROM in csp3) Hypertonicity of SCM, UFT, scalenes, sub-
occipitals, pect minor, pect major, lev scap4) Weak deep cervical flexors 5) Poor diaphramatic breathing- causing
overuse of accessory muscles of respiration6) Palpable joint dysfunction
Musculoskeletal features of cervicogenic headache
Regular overuse for >3months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
Peculiar pattern with characteristics shifting from migraine like to tension-like headache
Analgesics Ergotamine (migraine) Triptan (migraine and tension type) Opioid (opioid dependence; withdrawal
syndrome http://www.bbc.co.uk/news/health-19622016
Medication overuse Headache