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