HEADACHE

THE COPYRIGHTED MATERIAL AVAILABLE IN THIS PRESENTATION IS FOR EDUCATIONAL PURPOSES ONLY. REDISTRIBUTION IS NOT PERMITTED PER ATSU-SOMA.

Deborah M. Heath, D.O.With appreciation to Dr. Coppola for review slides

DISCLOSURE

• NOTHING TO DISCLOSE

• NO INVESTMENT IN DEVICES

• EXCEPT MY

UPON COMPLETION OF THIS PRESENTATION, PARTICIPANTS SHOULD BE ABLE TO:

1. DISCUSS COMMON TYPES OF PRIMARY AND SECONDARY HA’S.

2. DESCRIBE ANATOMY AND PATHOPHYSIOLOGY OF MIGRAINE HA’S.

3. DISCUSS TYPICAL SCREENING QUESTIONS FOR MIGRAINE HA’S.

4. DISCUSS THE TYPICAL PRESENTATION OF PRIMARY AND SECONDARY HA’S.

5. IDENTIFY IMPORTANT ANATOMICAL STRUCTURES SUCH AS:

-- SUBOCCIPITAL MUSCLES,

-- MUSCLES THAT CONNECT TO THE DURA

6. PERFORM OMT FOR THE MANAGEMENT OF HEADACHES. (LAB)

A

Headache

B

Primary

C

Migraine

DNon-

Migraine

E

Tension

F

Cluster

G

Other

H

Secondary

I

Intra-cranial

J

Vascular

K

Nonvascular

L

Cranial Neuralgias

M

PsychiatricN

Trauma

O

SubstanceP

Infection

Primary HA; no structural, infectious toxic/metabolic pathologies- “Endogenously” generated disorder- commonly genetic component- Attacks are separated by remissions of variable lengths.

Primary Headaches

Headache

Primary

Migraine Non-Migraine

Tension Cluster Other

Mixed Chronic daily headaches:Paroxysmal hemicranialIdiopathic stabbing; thunderclap Cold-stimulus/sinusBenign cough;Benign exertional; w/ sexual activity

3rd most prevalent disorder worldwide

2nd most prevalent

Global Burden of Disease Survey 2010 in: Coppola et al. Habituaion and sensitization in primary headaches. The Journal of Headache and Pain. 2013

PREVALENCE OF PRIMARY HEADACHES

• TENSION-TYPE HEADACHE IS THE 2ND MOST PREVALENT DISORDER WORLDWIDE

• MIGRAINE HA’S ARE THE 3RD MOST PREVALENT DISORDER WORLDWIDE

Global Burden of Disease Survey 2010 in: Coppola et al. Habituation and sensitization in primary headaches. The Journal of Headache and Pain. 2013 4: 65

MIGRAINE HEADACHES

Dr. Coppola

• EPISODIC MIGRAINE -RECURRENT; THROBBING, UNILATERAL, SEVERE

• FEMALES > MALES

• 50% GENETIC ( NO IDENTIFIED LOCI; CLINICAL & GENETIC HETEROGENEITY)

• 2/3 HAVE PERIORBITAL PAIN

• WITH AURA (30-35%) CORTICAL SPREADING DEPRESSION(CSD)

- VISUAL- ZIG ZAG FLASHES, SCOTOMA

- WEAKNESS

- SPEECH DIFFICULTY

- LASTS 5 TO 60 MINUTES.

• W/O AURA

• AURA ONLY

• CHRONIC MIGRAINE, DAILY PERSISTENT HEADACHE (NEW CLASSIFICATION)

INTERNATIONAL HEADACHE SOCIETY CLASSIFICATION FOR PRIMARY HEADACHE DISORDERS

Dr. Coppola

SCREENING FOR MIGRAINE – 3 SIMPLE QUESTIONSDISABILITY, NAUSEA, PHOTOPHOBIA

1. HAVE YOUR HA LIMITED YOUR ACTIVITIES FOR A DAY OR > IN PAST 3MO”S?

2. ARE YOU NAUSEATED OR SICK TO YOUR STOMACH WITH THE HA?

3. DOES LIGHT BOTHER YOU DURING A HEADACHE?

OK… IT’S MIGRAINE: (SPECIFIC QUESTIONS FOR MIGRAINE )

1. DO HA’S THAT INTERFERE WITH WORK, SOCIAL OR FAMILY FUNCTIONS?

2. HAS YOUR HA PATTERN BEEN STABLE OVER THE PAST SIX MONTHS?

3. HOW FREQUENTLY DO YOU EXPERIENCE HA’S?

4. HOW EFFECTIVE IS YOUR CURRENT HA TREATMENT?

CEREBROVENOUS SYSTEM SENDS SIGNALS TO THE TRIGEMINAL

Superior Sagital Sinus

MECHANISM OF MIGRAINE HA

1. INCREASED INFLAMMATORY MEDIATORS IN CEREBROVENOUS SYSTEM

2. ACTIVATES & SENSITIZES MENINGEAL PERIVASCULAR AFFERENTS

3. RELEASE OF VASOACTIVE PROINFLAMMATORY PEPTIDES -> CYTOKINES

FMRI shows activation of the spinal trigeminal nucleus caudalis (SpVC) during a migraine

Nosedo et al Migraine pathophysiology:Anatomy of the trigeminovascular pathway and assoc. neurological symptoms, cortical spreading depression, sensitization and modulation of pain. Pain 154(2013) S44-S53.1

Trigeminocervical Complex (TCC)

CONVERGENCE OF AFFERENTS (MENINGES, FACIAL SKIN, CERVICAL& JAW MUSCLES)

• NOCICEPTIVE AFFERENTS ENTER THE BRAINSTEM VIA THE TRIGEMINAL NUCLEUS AND

PASS CAUDALLY TO TERMINATE IN THE SPINAL TRIGEMINAL NUCLEUS(SPVC) THAT

EXTENDS TO C-3.

• LOCAL AFFERENTS (SKIN, NECK & JAW MUSCLES, VISCERA) CONVERGE ON THE SPINAL

TRIGEMINAL NUCLEUS. THIS CONVERGENCE LEADS TO “SOMATO-SOMATO AND

VISCERO-SOMATIC REFLEXES “

• INTRACRANIAL (VISCERAL) AND EXTRACRANIAL (SOMATIC) PRIMARY AFFERENTS

CONVERGE ONTO SPVC NEURONS RADIATE PAIN TO PERIORBITAL AND OCCIPITAL.

• THIS IS TERMED “SENSITIZATION” OF TRIGEMINOVASCULAR NEURONS IN THE

TRIGEMINOCERVICAL COMPLEX

Dr. Coppola

Myofascial Tender Point

Vasoconstriction

Hypertonic muscles

Convergence aka somatovisceral reflex

Suboccipital muscles innervated by Suboccipital N. (C1 Dorsal Ramus)

Convergence on Trigeminal spinal tract @ C1-3 excites suboccipital triangle muscles

Myodural bridge attaches Rectus capitis Minor, Major, and Obliquus Capitis inferior

a. Rectus Capitis Major

b. Cervical Dura Mater

Spinal cord

F. Scali et al. / The Spine Journal 13 (2013) 558–563

3 Suboccipital Muscles attach to the Dura

Myodural bridge (rectus capitis Major & Obliquus Capitis Inferior)Rectus capitis minor is not shown

Lateral view

DORSAL RAMI OF C1-C6- LATERAL BRANCHES

VENTRAL RAMUS OF C1 (CERVICAL PLEXUS)

(C1-C4)- innervates anterior and middle scalenes

Diaphragm & pericardium

PosteriorAnterior Neck

Dr. Coppola

TREATMENT APPROACHES FOR MIGRAINE

*NONPHAMACOLOGIC

• OMM

• BEHAVIORAL THERAPY

• EXERCISE/WEIGHT REDUCTION

• DIETARY CHANGES, REGULAR EATING & SLEEPING PATTERNS

• SMOKING CESSATION

*PHARMACOLOGIC TREATMENT (ACUTE AND PROPHYLACTIC)

• ACUTE: TRIPTANS (SUMATRIPTAN), DHE, NSAIDS,ANTI-EMETICS, CAFFEINE,

FEVERFEW, COQ10, MG, RIBOFLAVIN

*INTERVENTIONAL PROCEDURES

• NEUROBLOCKADE (NERVE, FACET, EPIDURAL SPACE)

• NEUROTOXIN TREATMENT (BOTOX)

• HOSPITAL/ REHABILITATION PROGRAMS

Serotonin (a vasoconstrictor); receptors in brain and brain stem- Low Serotonin levels found w/ Migraine -Triptans block pain impulses

Dr. Coppola

Serotonin Molecule Triptan Molecule

Objective: The aim of the RCT was to assess the effectiveness of OMT on chronic migraineurs using HIT-6 questionnaire, drug consumption, days of migraine, pain intensity, functional disability.

Methods: all pts. Admitted to Neurology Ancona’s United Hospitals, Italy, “migraine” (Int’n’l HA Society criteriaw/o chronic illness 1.) OMT: OMT + medication therapy (8 OMT visits over 6-months)2.) sham: sham + medication therapy 3.) control: medication therapy only.

Cerritelli,F. Clinical effectiveness of OMT in chronic migraine:3 armed RCT. http://neurologia.webposter.eu/web/eventi/pstneuro14/poster/pdf/pst133.pdf

Purpose: Effectiveness of OMT in the acute treatment and prophylaxis of migraine HA’s in females. RCT in Dresden, Germany.

Subjects: 42 subjects were randomized into 2 groups- intervention and control group. Each group had same medical treatment. OMT: 5 OMT (50 min) over a 10-week period. Measurements were taken @ baseline & 6-mos.

Outcomes: 1. The Migraine Disability Assessment (MIDAS) questionnaire-assesses migraine impact on the subject’s life, # days w/ migraine 2. The German “Pain Questionnaire” was used to measure pain intensity and disturbance in occupation due to the migraine. 3. SF-36 Health Survey was used to measure the subjects perceived health status and HRQoL.

Data-analysis: “intention-to-treat” design using SPSS 15.0 software. Baseline assessment were similar in both groups.Results:1. A statistically insignificant reduction of the number of days with migraine in both groups (19.2-23.1 days OMT,18.7-23.1 control)2. A statistically significant decrease in “disturbance to occupation due to migraine” in the intervention group.3. A statistically significant decreased in pain intensity in the intervention group vs. the control group.4. A statistically significant increase in vitality, mental health, bodily pain, & physical role functioning in the intervention vs. the control group.

The investigators concluded that OMT improved parameters in pain, HRQoL and working disability. Recommend a sham in future studies.

Voigt K, Liebnitzky J, Burmeister U, et al. Efficacy of Osteopathic Manipulative Treatment of Female Patients with Migraine: Results of a Randomized Controlled Trial. The Journal of Alternative and Complimentary Medicine 2011; 17:3pp225-230.

CHRONIC DAILY HEADACHES

Dr. Coppola

CHRONIC DAILY HEADACHE: (BASED ON FREQUENCY)

1. CHRONIC/ TRANSFORMED MIGRAINE, W/ OR W/O MED OVERUSE.

2. CHRONIC TENSION TYPE HA, W/ OR W/O MED OVERUSE.

3. NEW DAILY PERSISTENT HA-

-SUDDEN ONSET FOLLOWED BY PERSISTENT HA W/O PROGRESSIVE FEATURES OF

CHRONIC MIGRAINE

- OFTEN ASSOCIATED WITH COMORBID AND MED MISUSE.

4. HEMICRANIA CONTINUA: UNILATERAL GENERALLY PERSISTENT HEMICRANIAL

DISCOMFORT WITH SOME MIGRAINE OR CLUSTER HEADACHE FEATURES

- (OFTEN, THE RESULT OF HEAD TRAUMA, ACTUALLY A SECONDARY HEADACHE DISORDER).

Dr. Coppola

CHRONIC OR TRANSFORMED MIGRAINE –A PROGRESSIVE FORM OF MIGRAINE

INTERMITTENT EPISODES

• UP TO 15 OR MORE DAYS PER MONTH

- USUALLY STARTS WITH EPISODIC MIGRAINE WITHOUT AURA

- OFTEN ASSOCIATED WITH CO-MORBID NEUROPSYCHIATRIC PHENOMENA

- OFTEN ASSOCIATED WITH MED OVERUSE AND “REBOUND.”

- CO-MORBID CONDITIONS WITH MIGRAINE ) INCLUDE:

DEPRESSION, ANXIETY, PANIC ATTACKS, BIPOLAR DISORDER, FIBROMYALGIA

Dr. Coppola

CHRONIC TRANSFORMED MIGRAINE W/ MED OVERUSE (MOH) HEADACHE AKA “REBOUND”HA

WEEKS TO MONTHS OF EXCESSIVE USE OF ABORTIVE AGENTS, USAGE > 2-3 DAYS/WK

- INSIDIOUS INCREASE IN HA FREQUENCY

- PREDICTABLE HA CORRESPONDING TO ESCALATING USE OF SUBSTANCES AT REGULAR &PREDICTABLE INTERVALS

- EVIDENCE OF PSYCHOLOGICAL AND/OR PHYSIOLOGIC DEPENDENCY

- FAILURE OF ALTERNATIVE MEDICATIONS TO CONTROL HEADACHE ATTACKS

- RELIABLE ONSET OF HA WITHIN HOURS TO DAYS FOLLOWING THE LAST DOSE OF SYMPTOMATIC TREATMENT

A SELF-SUSTAINING HEADACHE, PROGRESSIVE

- HA WORSENED DURING MED OVERUSE

- HEADACHES > 15 DAYS PER MONTH; REGULAR USE OF ABORTIVE AGENTS >15 DAYS /MONTH FOR > 3 MONTHS

TREATMENT- CONTINUED USE OF MEDS MAKES PT REFRACTORY TO EFFECTIVE TX (RECEPTOR CHANGES)

- DISCONTINUE OFFENDING AGENT (TAPER IF OPIOID OR BARBITURATE)

- AGGRESSIVE TREATMENT OF “WITHDRAWAL” HA; HYDRATION, IV FLUIDS

- USE PHARMACOLOGIC PROPHYLAXIS

- BEHAVIORAL THERAPIES

- OMT

Dr. Coppola

TENSION TYPE HEADACHES: CONTROVERSIAL TITLE (SOME RELATE THIS TO A VARIANT FORM OF MIGRAINE)

• USUALLY BILATERAL PAIN

• NOT DISABLING, NO ASSOCIATED SENSORY SENSITIVITY &NAUSEA

• EPISODIC AND CHRONIC FORMS

• EPISODIC OVERLAPS MIGRAINE WITHOUT AURA (USUALLY W/O THROBBING PAIN OR ANS)

• CHRONIC TENSION TYPE HA- OVERLAPS FEATURES OF CHRONIC MIGRAINE

OCCIPITAL NERVE

• ORIGINATES FROM C2, C3

• PIERCES FASCIA, TRAPEZIUS AND ASCENDS THE SCALP

• INNERVATES SCALP TO VERTEX, EAR AND OVER THE

PAROTID GLANDS.

A

Headache

B

Primary

C

Migraine

D

Non‐Migraine

E

TensionF

ClusterG

Other

Male >female 3:1 - HA’s lasting weeks to months- 1 or >bouts/yr- Repetitive intense attacks- Unilateral orbital or temporal pain- Pounding pain- Lacrimation, nasal discharge, pupillary

changes, conjunctival injection, ptosis- Often triggered by alcohol ingestion

A

Headache

B

Primary

C

Migraine

D

Non-Migraine

E

TensionF

ClusterG

Other

*Mixed headaches*Chronic daily headachesParoxysmal hemicraniaIdiopathic stabbing or thunderclap headacheCold-stimulus/sinus headache Benign cough or exertional headacheHeadache associated with sexual activity

“Other” primary headachesExamples

Secondary Headaches

A

Headache

J

Vascular

K

Nonvascular

L

Cranial Neuralgia

M

Psychiatric

N

Trauma

O

Substance

P

Infection

I

Intracranial

H

Secondary

Secondary HeadachesExamples

Subarachnoidhemorrhage

Intracranialhematoma

Temporal arteritis

CSF pressurePost-spinal headachePseudotumor cerebriTumors Intracranial infections

(meningitis, encephalitis,intracerebral abscess)

Trigeminal neuralgiaOccipital neuralgia

Psychosis Post-traumatic Medicationinduced

Medicationwithdrawal

Systemic infections(influenza, sepsis)

Primary vs. Secondary Headache(how do you differentiate??)

History

*onset of headache?*previous headache?*family history?*concurrent illnesses?*pregnancy?*medications/

Neurologic ExaminationDr. Coppola

Secondary Headache Disorders:Most important tools are relevant history and competent neurologic and general examination.Diagnostic tests to consider in Refractory or Suspicious cases:

Besides, History and Physical /Neurologic Examination,Metabolic evaluation:

HematologicESR/CRP*EndocrineChemistryToxicology (drug screen)

NeuroimagingMRI/MRA/MRV*CT/CTA/CTVArteriography

Dental and otologic examinationLumbar puncture*

Dr. Coppola

Indications to consider neuroimaging for Headache

*Abnormal unexplained neurological exam (learn and practice).*Onset of headache over age of 55.*Associated fever.*Headache with extremely abrupt onset.*Headache refractory to aggressive treatment.*First or “worse” headache ever experienced.*Increasing frequency and/or severity of headaches.*Change in headache clinical features.*Headaches that don’t “fit” primary headache criteria.**

For children: *morning/nocturnal headache (especially 3 y.o. or less).*explosive onset headache.*progressive worsening over time.*declining school performance/personality changes.*altered mental status.

Dr. Coppola

“I want men and women to study Osteopathy who reason and think for themselves. It is never a question as to what the remedy or the treatment will do to the body, but what the body will do with the remedy or treatment.”

A.T. Still

Question: Can pain @C1 be reduced by light circular pressure on trigeminal facial sites?Participants: 50 asymptomatic subjects (30 female;15 male) age 32.1 ± 11.32Methods:

- Rate pain 0-10 @ C1(rectus capitus minor; (right/left) with light pressure

- Rate pain 0-10 @ facial trigeminal (Supraorbital , infraorbital, mental)

- Identify most painful foramen- Apply light circular pressure @ pain site until zo

pain.- Reassess C1 pain

0 0.25 0.50 0.75 1.0 1.25 1.5 1.75

0 0.25 0.50 1.0 1.25 1.50 1.75 2.0 sec

2.0 sec

0.75

0 0.25 0.50 1.0 1.25 1.50 1.75 2.0 sec0.75

t

t

t

Frequency: 1 Hz = 1 beat per secondTime Interval: 1 second between beats

Frequency: 2 Hz = 2 beats per secondTime Interval: 0.5 seconds between beats

Frequency: 4 Hz = 4 beats per secondTime Interval: 0.25 seconds between beats

1 Hz

2 Hz

4 Hz

Things Aren’t Always as they Appear

REFERENCES

• WOOLF CJ (2011) CENTRAL SENSITIZATION: IMPLICATIONS FOR THE DIAGNOSIS AND TREATMENT OF PAIN. PAIN 152:S2–S15.

• FERNÁNDEZ-DE LAS PEÑAS C, GALÁN-DEL RÍO F, ALONSO-BLANCO C ET AL (2010) REFERRED PAIN FROM MUSCLE TRIGGER POINTS IN THE MASTICATORY AND NECK-SHOULDER MUSCULATURE IN WOMEN WITH TEMPOROMANDIBULAR DISORDERS. J PAIN 11:1295–1304.

• GREENSPAN JD, SLADE GD, BAIR E ET AL (2011) PAIN SENSITIVITY RISK FACTORS FOR CHRONIC TMD: DESCRIPTIVE DATA AND EMPIRICALLY IDENTIFIED DOMAINS FROM THE OPPERA CASE CONTROL STUDY. J PAIN 12:1–25.

• FERNÁNDEZ-DE LAS PEÑAS C, GALÁN-DEL RÍO F, FERNÁNDEZ-CARNERO J ET AL (2009) BILATERAL WIDESPREAD MECHANICAL PAIN SENSITIVITY IN WOMEN WITH MYOFASCIAL TEMPOROMANDIBULAR DISORDER: EVIDENCE OF IMPAIRMENT INCENTRAL NOCICEPTIVE PROCESSING. J PAIN 10:1170–1178.

Thank you from ATSU SOMA

Deborah Heath, DO

Mindy Hansen MS, OMS IV

TRIGEMINAL STIMULATION WITH OA RELEASE AND CERVICAL BLT

LAB

1.Palpate for Pain @ C1 (right & left) - rate pain 0-10.2. Palpate facial trigeminal foramen. (Supraorbital , infraorbital, mental) - rate pain 0-10- Select most tender site over the

foramen- Lightly press with circular motion

until pain is zero. 3. Reassess C1 pain.

CONFLUENCE OF SINUSES

Middle finger at inion

Very gentle lateral “traction

Some may raise middle fingers so the weight of the skull rests on them

Wait for softening of cranium

SUPERIOR SAGITTAL SINUS

Beginning at the external occipital protuberance, cross thumbs over to contact on each side of the sagittal suture

Apply pressure to the thumbs to separate the sagittal suture

Hold each point, along the suture to the bregma, until you feel a softening

OCCIPITO-ATLANTAL RELEASE

1. PHYSICIAN SEATED AT HEAD OF TABLE.

2. PLACE INDEX AND MIDDLE FINGERS @ MIDLINE

OF OCCIPUT/C1

3. APPLY CEPHALAD TRACTION ALLOWING YOUR

FINGERS TO CREEP INTO THE TISSUE.

4. ADD LATERAL TRACTION AT YOUR FINGERS BY

APPROXIMATING WRISTS.

5. ADD RESPIRATORY ASSIST.

6. REPEAT AND RECHECK

1. PATIENT SUPINE, PHYSICIAN AT HEAD

2. CRADLE HEAD IN PALMS AND FINGERTIPS CONTACT BOTH LATERAL MASSES OF ATLAS

3. ROTATE ATLAS TO LEFT TO POINT OF BALANCE

4. ADJUST SIDEBENDING AND FLEXION OR EXTENSION

5. TEST RESPIRATORY PHASES AND ADD ASSIST

6. MAKE MINOR ADJUSTMENTS IN ALL 3 PLANES

7. REPEAT UNTIL BEST MOTION IS OBTAINED

8. RECHECK

SUPINE BLT TREATMENT WITH RESPIRATORY FORCE –AA RL

ANTERIOR C 1 (USUALLY ON RIGHT)

1.Palpate for Pain @ C1 (right & left) - rate pain 0-10.2. Palpate facial trigeminal foramen. (Supraorbital , infraorbital, mental) - rate pain 0-10- Select most tender site over the

foramen- Lightly press with circular motion

until pain is zero. 3. Reassess C1 pain.