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Sarah Watson OMS V, Therese Obioha OMS V June 26, 2013 Original Presentation by: Tim Neely OMM PCA Osteopathic Approach to Headaches 1

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Headaches One of the most common complaints in the Family Practice and Emergency Room.. treated with medicationsand OMM 2

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Overview of Lab Overview of headaches Causes Differential Diagnoses Osteopathic Approach to Headaches Goals Treatments Practice Time Wrap-Up Summer Scholars 3

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Overview of Headaches 4

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The Brain is insensitive to painso why do we get headaches? 5 Pain Sensitive Areas: Intracranially Dura (surrounding the brain) Venous Sinuses Arteries in the pia matter and the arachnoid space Extracranially Skin Muscles Fascia Arteries Therefore, pain develops from dysfunction, displacement, or encroachment on one of the above structures (Foundations, pg 437)

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Overview of Headaches - Causes Most Common Causes 1. Tension Headache 2. Migraine Headache 3. Cluster Headache Other Causes 1. Intracranial Bleeding 2. Brain Neoplasm 3. Sinus Headache 4. Hypertension - Uncontrolled 6

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Tension Headaches: Most common cause of headaches Causes Muscle hypertonicity Postural causes Emotional Stress Symptoms: Squeezing pain Describe as a band-like pain Bilaterally No nausea or vomiting (unless severe) 7

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Migraine Headaches Etiology ? thought to be related to disordered control of the craniao-cerebral circulation Recurrent and runs in families Associated with certain triggers Symptoms Throbbing pain Associated nausea and vomiting common Aura may be present Relieved by sleep Sensitivity to light, sounds Symptoms can be debilitating 8

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Cluster Headaches Cause: neurogenic inflammation affecting the vascular plexus of the cavernous sinus Symptoms: Periorbital Pain Develop quickly and increase in pain rapidly Occurs 2-3 hours after onset of sleep Autonomic Features: rhinorrhea, unilateral lacrimation, ptosis More common in men 9

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Osteopathic Approach to Headaches 10

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OMM Approach to Headaches First Correct Diagnosis Use history and physical exam and check vitals Tension vs. Migraine vs. Cluster vs. other cause Second Correct Structural Diagnosis Screen, Scan, Segmental Diagnosis Third Treatment OMM Medications Home Exercises Fourth Follow-up 11

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OMM Approach to Headaches Case Example: Pt is 34 yo Female presenting with 1 month history of headache. Pain is described squeezing. It located at the back of head and wraps around to her forehead. No nausea/vomiting/visual disturbances. Advil does not help. Sleep does not help. MedHx: Advil. FamHx: None relevant Social: Pt has a desk job and works 10 hours a day, has 3 children. Patient does not use EtOH, tobacco, or illicit drugs. 12

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OMM Approach to Headaches What type of headache is most likely described? Tension Headache What areas may be involved? 13

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OMM Approach to Headache Areas to consider: Cervical Spine and Musculature Thoracic Spine and Musculature Cranial Bones and Sinuses Also consider Sacro-pelvis Lumbar Spine Lower Extremity 14

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OMM Approach to Headaches Muscular Involvement of the Head and Neck Frontalis Temporalis Occipital Sternocleidomastoid Scalenes Levator Scapuli Trapezius Lets think about the attachments of these muscles 15

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Treatments and Practice 16

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Headache Treatments 17 Suboccipital Release 1. Patient supine 2. Find the base of the skull 3. Place pads of fingers (both hands) into the occipital sulcus 4. Rest weight of head on fingers 5. Wait for muscles to relax 6. Re-check

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Headache Treatments 18 Cervical Muscles: Cross Arm Stretch Pt supine Physicians forearms crossed under patients neck and hands are placed on anterior aspect of patients shoulders Physician lifts patients head until the muscular restrictive barrier met Force slowly relaxed Stretching may be repeated Recheck

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Headache Treatments 19 Trapezius Inhibition 1. Patient Supine 2. Physician places thumb on anterior side of upper trapezius, and fingers on posterior aspect of upper trapezius 3. Physician gently adds a squeezing force between thumb and fingers 4. Continue until trapezius relaxes

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Switch Partners 20

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Headache Treatments 21 Trapezius Release (Upper) 1. Patient prone 2. Use the thumb and thenar eminence of the hand to contact muscular targets 1. Upper trapezius, hands at the patients shoulder, fingers wrapped around superior border 3. Physician applies gentle traction on the muscle to stretch 4. Hold, Release, Repeat 5. Recheck

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Headache Treatments 22 Trapezius Release (Lower) 1. Patient prone 2. Use the thumb and thenar eminence of the hand to contact muscular targets 1. Lower Trapezius, hands below the scapular, force directed laterally 3. Physician applies gentle traction on the muscle to stretch 4. Hold, Release, Repeat 5. Recheck

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Headache Treatments 23 Lumbo-Sacral Traction 1. Patient Prone 2. Physician uses heel of one hand on sacrum, and heel of opposite hand on lumbar musculature 3. Physician exerts gentle force with both hands, pushing away from each other 4. Gently, rhythmic kneading or deep inhibitory pressure may be used 5. Recheck

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Everyone at the Same Time 24

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Headache Treatment - Stretches 25 Head up straight Deep breath to relax muscles of head and neck Roll shoulders back

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Headache Treatments - Stretches 26 Neck Stretch: 1. Tip head to one side, bringing the ear and shoulder together 2. Place hand on same side on top of head, using gravity to deepen stretch 3. Stretch should be felt on the side of the neck, it should NEVER hurt 4. Repeat on opposite side

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Headache Treatment - Stretches 27 Thoracic Stretch: 1. Sit on stool/chair, feet on the floor. 2. Drop arms between legs, allow head and back to fall forward.

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OMM and Headaches Putting it All Together 28 Common Complaint OMM as an adjunct with traditional medical therapy Remember 1. Diagnose Correctly 2. Develop Treatment Plan 3. Follow-up treatment DEMO Dr. Rettos headache treatments sequence

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References Foundations for Osteopathic Medicine, 436-441. DiGiovanna, E.L. An Osteopathic Approach to Diagnosis and Treatment, 137-142,158-168, 194-195. Nicholas, A. Atlas of Osteopathic Technique. pg. 99, 106