DIFFERENTIATING HEADACHES WITH A FOCUS ON
CERVICOGENIC HEADACHE and
MIGRAINEDr. Amy Pakula PT, DPT, OCS, FAAOMPT
2019 Montana Physical Therapy Summit
Almost every human experiences headache during their lifetime
Globally, 47% of adults have an active headache disorder
Economic burdenOf Migraine in the US = 36 Billion
▸ ‘I’m scared to travel for fear of having a migraine and it ruining my trip…’
▸ ‘I feel like I have no energy and snap at people, even my family…’
▸ ‘I’ve had to miss work or school because of my headaches, people think I’m a slacker, if they only knew…’
▸ ‘I just want to have some control over this…’
INDIVIDUAL BURDEN OF HEADACHE & MIGRAINE
WHY DO I CARE ABOUT HEADACHE AND MIGRAINE TREATMENT/MANAGEMENT?
WHY DO I CARE ABOUT HEADACHE AND MIGRAINE MANAGEMENT?
WHY DO I CARE ABOUT HEADACHE AND MIGRAINE MANAGEMENT?
THE CHALLENGE OF HEADACHE/MIGRAINE MANAGEMENT & TREATMENT
▸ 70-90% of adults have a minimum of one headache per year ▸ Accurately identifying HA type is critical to appropriate
management▸ Significant overlap in signs and symptoms of different HA types▸ Can have more than one HA type ▸ Primary care providers may not have the time or ability to perform
detailed exam
THE PHYSICAL THERAPIST’S OPPORTUNITY IN HEADACHE/MIGRAINE TREATMENT AND MANAGEMENT
▸ 70-90% of adults have a minimum of one headache per year ▸ Accurately identifying HA type is critical to appropriate
management▸ Significant overlap in signs and symptoms of different HA types▸ Can have more than one HA type ▸ Primary care providers may not have the time or ability to
perform detailed exam
COMMON HEADACHE CATEORIES
International Classification of Headache Disorders (ICHD)
Primary Headaches
▸ NO structural or metabolic abnormality
▸ NOT a symptom of or caused by another disease or condition
Secondary Headaches
▸ Structural or metabolic abnormality
▸ A symptom of or caused by an underlying disease or condition
International Classification of Headache Disorders (ICHD)
International Classification of Headache Disorders (ICHD)
Primary Headaches
▸ Tension Type▸ Migraine▸ Trigeminal
autonomic cephalalgias
Secondary Headaches
▸ Cervicogenic
What we are covering in this lecture
International Classification of Headache Disorders (ICHD)
Episodic
▸ 14 days/month or less
Chronic
▸ 15 days/month or more
PRIMARY HEADACHES
TENSION TYPE HEADACHE
▸ Lifetime prevalence ranges from 30-78%▸ Least studied of the primary headache
disorders▸ The exact mechanisms of TTH are not
known▸ Often presents with other headache types
TENSION TYPE HEADACHE
▸ 30 min - 7 day duration▸ At least two of the following
▹ Bilateral location▹ Pressing/tightening (non-pulsating) quality▹ Mild or moderate intensity▹ Not aggravated by routine physical activity
▸ Both of the following▹ No nausea or vomiting▹ One or none of photo or phonophobia
MIGRAINE
MIGRAINE
▸ Affects 39 million in the US▸ Affects 18% of women, 6% of men, and 10% of children▸ 3x as common in women vs men▸ 6th most disabling illness in the world▸ Thought to be a neurovascular pain syndrome
with altered central neuronal processing and involvement of the trigeminovascular system
MIGRAINE
▸ Migraine without aura▸ Migraine with typical aura
▸ Other (less common):▹ Hemiplegic migraine▹ Vestibular migraine▹ Migraine with brainstem aura▹ Typical aura without headache
AURA
▸ Fully reversible transient neurological symptoms▸ Lasts 5 - 60 min▸ Most common are increased visual auras,
altered sensation affecting unilateral face or body, changes in speech or language
▸ Clear temporal relationship between aura and headache
MIGRAINE WITH TYPICAL AURA
▸ One or more of the following fully reversible aura symptoms▹ Visual features (most common)▹ Sensory features unilaterally▹ Speech and/or language
▸ At least two of the following▹ At least one aura symptom spreads gradually over 5 minutes,
and/or two or more symptoms occur in succession▹ Each individual aura symptom lasts 5-60 minutes▹ At least one aura symptom is unilateral▹ Aura is accompanied, or followed within 60 minutes, by
headache
MIGRAINE WITHOUT AURA
At least five attacks fulfilling criteria
▸ Headache attacks lasting 4-72 hours [when untreated]▸ At least two of the following
▹ unilateral location▹ pulsating quality▹ moderate or severe pain intensity▹ aggravation by or causing avoidance of routine
physical activity▸ At least one of the following
▹ Nausea and/or vomiting▹ Photophobia and phonophobia
TRIGEMINAL AUTONOMIC CEPHALALGIAS
TRIGEMINAL AUTONOMIC CEPHALALGIAS
▸ Cluster headache, paroxysmal hemicranias, SUNA/SUNCT, hemicrania continua▸ a group of headache disorders characterised by attacks
of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features such as lacrimation, conjunctival injection, rhinorrhoea, nasal congestion, eyelid oedema and ptosis
▸ Less common, relatively rare
SECONDARY HEADACHES
CERVICOGENIC HEADACHE▸ Incidence: 14-18% of all chronic HAs
and 15-20% of all HAs▸ Originates from the upper cervical
(C0-3) nerves, joints, discs, ligaments, or muscles
▸ As physical therapists, these are the patients we want to be seeing a full caseload of!
CERVICOGENIC HEADACHE
▸ Pain localized in the neck and occiput, which can spread to other areas in the head, usually unilateral
▸ Pain is precipitated or aggravated by specific neck movements or sustained postures
▸ At least one of the following▹ Limited Neck ROM▹ Changes in neck muscle tone, or response to
active/passive stretching and contraction▹ Abnormal tenderness of neck musculature
A BRIEF ANATOMY INTERLUDE
TRIGEMINOCERVICAL NUCLEUS
TRIGEMINOCERVICAL NUCLEUS▸ Convergence of trigeminal nerve and upper cervical
nerve roots▹ Convergence allows for nociception from upper
cervical spine to be perceived as arising from▹ Regions of the head innervated by other
cervical nerves▹ Regions of the head innervated by 1st
division trigeminal afferents▹ Can activate trigeminovascular
neuroinflammatory cascade
TRIGEMINOCERVICAL NUCLEUS
Inputs to the trigeminocervical nucleus:● C1, C2 and C3 Afferents● Trigeminal Nerve Afferents
○ face, jaw, and teeth
Chronic nociceptive input can lead to sensitization
CONVERGENCE OF TCN
▸ Neck can refer to the head▸ Head can refer to the neck
▹ Convergence is bidirectional
NECK PAIN AND HEADACHE▸ 50-80% of primary and non cervicogenic secondary headaches
have associated neck pain
▸ NECK PAIN + HEADACHE does not equal PRIMARY CERVICOGENIC ORIGIN OF HEADACHE
HOWEVER...
NECK PAIN AND HEADACHE
▸ The presence of neck pain in patients with migraine was associated with the presence of cutaneous allodynia, a reduced upper cervical range of motion (C1-C2), and poor neck muscle performance compared to that in patients with migraine not reporting neck pain.
NECK PAIN AND HEADACHE
▸ Cervicogenic influence in migraine and/or tension type headache presentations
▸ Migraine mechanisms involve the trigeminovascular system
“A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment.”
- Sir William Osler
SUBJECTIVE EXAM
▸ One type of headache? Or multiple?▸ Each type
▹ Location▹ Intensity▹ Duration▹ Quality▹ Frequency
▸ Headache free days?
▸ Headache Tracking Apps▹ My Migraine Buddy http://app.migrainebuddy.com/▹ iHeadache http://iheadache.com/
SUBJETIVE EXAM SPECIFIC FOR HEADACHE
▸ Headache and neck pain relationship▹ Neck referring to head?▹ Head referring to neck?▹ Related or unrelated?▹ With migraine
▹ Neck pain can be a trigger, premonitory, referred, or unrelated
SUBJETIVE EXAM SPECIFIC FOR HEADACHE
HEADACHES THAT MAY NEED FURTHER DIAGNOSTIC TESTING
● First or worst headache● New onset of headache > 50 years old● New onset with immunodeficiency or history of cancer● Headache with mental status changes● Headache with fever and neck stiffness or meningeal signs● Headache with focal neurologic deficits if not previously
documented as migraine with aura● Increased frequency or severity of headache
(Detsky, 2006)
HEADACHES THAT MAY NEED FURTHER DIAGNOSTIC TESTINGSNOOP 4 SNOOP 1 ▸ Cervical AROM
▹ Overpressure, combined motions, sustained, repeated motions ▸ Cervical PAIVMs
▹ C0-C3 good reliability, high sensitivity and a low negative likelihood ratio (Zito, 2006)
▸ Soft tissue palpation▸ TMJ Clearing (at minimum)
▹ Opening, closing, lateral deviation▹ Up to 44% of CGHA may have comorbid TMJ issues/symptoms (von Piekartz, 2011)
▸ Thoracic and Shoulder Clearing▸ Assessing for pain, stiffness, and/or reproduction of headache
OBJECTIVE EXAM
OBJECTIVE EXAMCervical Flexion Rotation Test
•Examines ROM at C1-2
•Average normal ROM is 40-44 degrees
•(+) test if ROM < 32 degrees
•High sensitivity (91%) and specificity (90%) for cervicogenic HAs (Ogince, 2007, Hall, 2010)
OBJECTIVE EXAMCervical Flexion Rotation Test
The cervical flexion-rotation test (CFRT) exhibited both the highest reliability and the strongest diagnostic accuracy for the diagnosis of CGH (Rubio-Ochoa, 2015)
OBJECTIVE EXAMDeep Neck Flexor Endurance/Motor Control
● Gently and slowly nod the head as if saying “yes” pressure sensor measures 2 mmHg above baseline, then 4mmHg, followed by 6mmHg, 8mmHg, and 10mmHg without rests in between (the pressure sensor should read 30mmHg at the end of the movement sequence).
● Hold each increment for 2 seconds, 10 seconds total after all 5 increments.
● Repeat the highest level achieved with correct form until a total of 10 reps with 10 second holds are achieved. (Jull, 2008)
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
▸ Cervicogenic ▹ “A combination of mobilization, manipulation, and
cervico-scapular strengthening exercises may be the most effective intervention based on the results of this systematic review” (Racicki, 2013)
▹ “Current RCTs suggest that physiotherapy and spinal manipulative therapy might be an effective treatment in the management of cervicogenic HA” (Chaibi, 2011)
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
▸ Migraine▹ “Spinal manipulation may be an effective
therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary.”
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
▸ Migraine▹ “The most likely tests for evaluation of
musculoskeletal impairments in migraine are range of cervical motion, the flexion-rotation test, and forward head posture in a standing position, as well as manual joint testing and evaluation of trigger points” (Szikszay, 2019)
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
▸ Migraine, cervicogenic, tension type headache▹ “Physiotherapy interventions resulted in a statistically
significant effect on the intensity of tension-type headache (TTH) and cervicogenic headache (CGH), the frequency of CGH, and the duration of migraine and CGH when combined in meta-analyses” (Luedtke, 2016)
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
WHAT HEADACHE TYPE(S) RESPOND TO PHYSICAL THERAPY?
▸ Migraine▹ Decrease intensity and/or frequency
▹ Decrease risk of development of chronic HA▹ Decrease medication use
▹ Avoidance of potential negative side effects▹ Decrease risk of medication overuse HA
▹ Increase interal locus of control and self efficacy
TREATMENT TECHNIQUESUpper Cervical Mobilization/Manipulation
● “Mobilization or manipulation of the cervical spine may be beneficial for individuals who suffer from cervicogenic HA” (Garcia, 2016)
CRITICAL THINKING & DECISION MAKING
REASSESSMENT OF ASTERISKS WITHIN AND BETWEEN VISITSCervical Flexion Rotation Test
TREATMENT TECHNIQUESC/T Junction Mobilization/ManipulationThoracic Mobilization/Manipulation
TREATMENT TECHNIQUESDeep Neck Flexor Training Cervicoscapular and Scapular Training
TREATMENT TECHNIQUESAddress soft tissue
TREATMENT TECHNIQUESHome Exercises
TREATMENT TECHNIQUES
Focus is on two areas1. Decreasing the central sensitization with
interventions targeting the central nervous system (cognitive/educational aspects and medication) and the peripheral nervous system (manual therapies)
2. Increasing the activation of descending inhibitory systems (exercise and pain neuroscience education)
Central Sensitization
TREATMENT TECHNIQUESPatient Education
What triggers a headache or migraine?
TREATMENT TECHNIQUESPatient Education
What triggers a headache or migraine?
TREATMENT TECHNIQUESPatient Education
How can physical therapy help?
- Treats muscles, joints, ligaments, nerves
- Mobilization, manipulation, soft tissue work, exercise, stretching, retraining movements
- Removes some water from the glass, turns down the alarm system
TREATMENT TECHNIQUESPatient Education
Wholistic and Self Managemet Strategies
SEEDS- Sleep- Eating- Exercise - Drinking - Stress Management
TREATMENT TECHNIQUESPatient Education
Stress Management
TREATMENT TECHNIQUESPatient Education
Stress Management
- Deep breathing- Meditation or mindfulness- Set boundaries- Anxiety at onset of symptoms
SUMMARY•Headache diagnosis can be challenging and patients often present with more than one headache type concurrently•Physical therapy is a safe, effective, low cost intervention•Physical therapy can resolve cervicogenic headaches and can help manage migraine and tension type headaches
ADDITIONAL RESOURCES
Headache Disability Index Migraine Disability Assessement (MIDAS)American Headache Society
https://americanheadachesociety.org/American Migraine Foundation
https://americanmigrainefoundation.org/
Migraine Case Study
- 38 Year old female - Dental hygienist- 15 year history of migraine with aura- 10-12 migraine days per month over the past 2 years
(frequency has been increasing slightly in the past 6 months)
- Taking 9-10 doses of Maxalt per month- Concerned about medication overuse headaches
- Upper cervical and cervicothoracic hypomobility- (+) cervical flexion rotation test on right- Limited deep neck flexor endurance
- Increased stress and work hours over the past 6 months with job promotion
- Sleep quantity and quality – poor- Exercise/daily movement – infrequent
- Treatment consisted of manual intervention to upper cervical and cervicothoracic junction.
- Deep neck flexor endurance training- Addressing lifestyle, stress management, and
sleep hygiene
- 8 visits over 3 months- Cervical and CT junction hypomobility improved- Sleep hygiene and stress management strategies
being implemented- Exercise/daily movement – unchanged - 3-4 migraine days per month
Cervicogenic HeadacheCase Study
Aggs / Eases
Aggravating● Working at laptop >1.5 hours,
brings on neck pain then HA, can continue working as long as needed, eases in 1-2 hours with neck stretching
● Right rotation stiff and brings on neck pain if sustained more that 1-2 minutes, eases OOP in 1-2 minutes
Easing● Neck stretches● IBU● Lying supine
24 Hour Pattern
PM● Does not wake secondary to neck pain or HA
AM● Occasional stiffness/soreness in R occipital region,
eases within a few minutes
DAY● Symptoms depend on activity, how much time at
computer or right rotation
Current and Past History
● Current Hx - 6 mo hx of neck pain that came on after 3 day biking trip. HAs began about 3 months ago. HAs come on 4-5x week and last from 2-8 hours. HAs and neck pain have been worsening over the past month (increased intensity of HA and neck pain).
● Past Hx - Past hx of ‘tension type’ HAs in graduate school, no significant neck pain or HAs since then
THANKS!
Phys Ther. 2019 Jan 28. Which Examination Tests Detect Differences in Cervical Musculoskeletal Impairments in People With Migraine? A Systematic Review and Meta-Analysis.Szikszay TM1, Hoenick S2, von Korn K3, Meise R4, Schwarz A5, Starke W6, Luedtke K7.
Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review.Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE.Man Ther. 2016 Feb;21:35-40. doi: 10.1016/j.math.2015.09.008. Epub 2015 Sep 21. Review.
Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials.Chaibi A, Russell MB.J Headache Pain. 2014 Oct 2;15:67. doi: 10.1186/1129-2377-15-67. Review.PMID: 25278005
Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review.Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M.J Man Manip Ther. 2013 May;21(2):113-24.
Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Spinal manipulative therapy in the management of cervicogenic headache. Headache. 2005;45:1260–3.
Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13:351–9.
Therapeutic exercise as treatment for migraine and tension-type headaches: a systematic review of randomised clinical trials..Gil-Martínez A, Kindelan-Calvo P, Agudo-Carmona D, Muñoz-Plata R, López-de-Uralde-Villanueva I, La Touche R.Rev Neurol. 2013 Nov 16;57(10):433-43
Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis.Luedtke K, Allers A, Schulte LH, May A.Cephalalgia. 2016 Apr;36(5):474-92.
Spinal manipulations for cervicogenic headaches: a systematic review of randomized clinical trials.Posadzki P, Ernst E.Headache. 2011 Jul-Aug; 51(7):1132-9
Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence?Garcia JD, Arnold S, Tetley K, Voight K, Frank RA.Front Neurol. 2016 Mar 21;7:40.
Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study.von Piekartz H, Lüdtke K.Cranio. 2011 Jan;29(1):43-56.
Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial.Haas M, Spegman A, Peterson D, Aickin M, Vavrek D.Spine J. 2010 Feb;10(2):117-28.
Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache.Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.J Orthop Sports Phys Ther. 2007 Mar;37(3):100-7.
Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache.Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC.J Orthop Sports Phys Ther. 2006 Mar;36(3):160-9.
Spinal manipulative therapy in the management of cervicogenic headache.Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA.Headache. 2005 Oct;45(9):1260-3.
Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache.Zito G, Jull G, Story I.Man Ther. 2006 May;11(2):118-29. Epub 2005 Jul 18.
Predictors of responsiveness to physiotherapy management of cervicogenic headache.Jull GA, Stanton WR.Cephalalgia. 2005 Feb;25(2):101-8.
Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study.Haas M, Groupp E, Aickin M, Fairweather A, Ganger B, Attwood M, Cummins C, Baffes L.J Manipulative Physiol Ther. 2004 Nov-Dec;27(9):547-53.
The flexion-rotation test and active cervical mobility--a comparative measurement study in cervicogenic headache.Hall T, Robinson K.Man Ther. 2004 Nov;9(4):197-202.
Cervicogenic headache: locus of control and success of treatment.Stanton WR, Jull GA.Headache. 2003 Oct;43(9):956-61.
A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C.Spine (Phila Pa 1976). 2002 Sep 1;27(17):
Efficacy of spinal manipulation for chronic headache: a systematic review.Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L.J Manipulative Physiol Ther. 2001 Sep;24(7):457-66.
The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis.Rist PM, Hernandez A, Bernstein C, Kowalski M, Osypiuk K, Vining R, Long CR, Goertz C, Song R, Wayne PM.Headache. 2019 Apr;59(4):532-542. doi: 10.1111/head.13501. Epub 2019 Mar 14.
