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Cephalalgia
Department of Osteopathic Manipulative Medicine
University of North Texas Health Science Center
Texas College of Osteopathic Medicine
Case Presentation
A 32-year-old female presents to the office with a 10 year history of headaches. The headaches often begin with a sensation of flickering lights. Later she notes a throbbing sensation, usually right or left-sided. She also describes a pressure-like, tight sensation occurring in the occipital area.
Case Presentation
When the headaches are severe, bright lights and strange smells may provoke or worsen the intensity. The patient will then prefer a dark room.
A severe headache in this patient will last several hours. She also describes a chronic, dull achy headache which has lasted several days.
ROS
No history of head trauma, seizure disorder, or CNS infections.
Family history of similar headaches in mother, and maternal grandmother.
Physical Examination
WDWN female in NADAlert, oriented x 3Funduscopic – sharp discs, no hemorrhages,
or exudatesPERRLACN 2-12 intact
Musculoskeletal
Tenderness, tightness suboccipital muscles Elevated left 1st rib with surrounding spasm Increased spasm in the cervical
paravertebral mm. C3 – C5, RR SR
AA – RR OA – SR RL
T1 – T4 Increased sympathetic tone, loss of normal kyphotic curvature, SR RL
Secondary Headache (Differential)
Glaucoma Cerebral Aneurysm Temporal Arteritis Optic Neuritis Carotid or Vertebral a. dissection TMJ Syndrome Herpes Zoster Meningitis/Encephalitis Sinusitis/Facial Osteomyelitis
Secondary Headache (Other Causes) Intracranial Hypertension Benign Intracranial Hypertension Exertional Headache (Lift, Cough, Strain) Normal Pressure Hydrocephalus Myofascial Pain Syndrome Subarachnoid Hemorrhage Subdural Hematoma Viremia
Secondary Headache (Other Causes) Stroke Vasculitis Cervical Spine Disorder Dental Disorder Anemia Caffeine Withdrawal Fever Hypercapnea Hypoxia
Zomig, 2.5 mg at onset of headache
Repeat x1 in 2 hours if headache is not resolved Naprosyn 500 mg p.o. Bid. p.c.
Treatment
Very common in primary care
What can be done osteopathically?
Mixed Headache with associated Cervical Pain
Headache
Most common headache is tension. Many patients with migraine headache have
coexisting tension headache.
Trigeminal Nucleus Caudalis
Major Relay Nucleus for head and neck pain. Vascular Headache (Migraine)
Nociceptors Vascular Nonnoxious Stimuli Vascular Pulsations
Tension Headache Nociceptors Myofascial Nonnoxious Stimuli Muscle Contractions
Areas to Treat Osteopathically
Sympathetic Lower Cervical Upper T-Spine Associated ribs and myofascial
attachments
Parasympathetic Suboccipital Region
Treatments Suboccipital Inhibition Suboccipital Inhibition
Pads of fingers just beneath superior nuchal line in suboccipital soft tissue.
Weight of head rests on pads of fingers.
Treatments 1st Rib Muscle Energy
1st Rib Muscle Energy Pads of thumbs on rib heads directly in front of
trapezius. Patient should shrug both shoulders towards ears
while taking a deep breath. Patient should release breath slowly while letting
shoulders down. Continue maintaining firm caudad pressure and
follow the rib caudally through exhalation maintaining new position. (Barrier)
TreatmentsCervical Muscle Energy Diagnosis of Somatic Dysfunction
C-Spine Side-bending Rotate each segment
TreatmentsCervical Muscle Energy Cervical Muscle Energy (C2 – C7)
Induce side-bending to restrictive barrier with pad of thumb.
Flex or extend neck to localize to particular segment.
Have patient side-bend away from barrier. Side-bend patient to new restrictive barrier.