Cephalgia - SS Flashcards
What are the primary types of headaches?
–Tension-Type (TTH)
–Migraine
–Cluster
What are the secondary types of headaches?
–Rebound
•Medication (OTC) overuse
–Manifestation of other
diseases
What is the most common precipitating factor for TTH? What are other causes?
- Stress and mental tension
- Head and neck movements and postures
- Anxiety and depression
- Fatigue
- Structural Abnormalities
- Viscerosomatics
What happens to a persons body who sits at work regularly?
–The upper neck bends backwards causing the suboccipital muscles to tighten
–Pectoralis minor muscle subsequently tightens
–Trapezius fibers weakened or atrophy
What are the seven pain sensitive structures in the head?
- •Skin and its blood supply
- •Muscles of the head and neck
- •Venous sinuses and their tributaries
- •Parts of the dura mater – base of the brain
- •Dural arteries
- •Intracranial arteries
- •Cranial nerves
What are the two pain mechanisms for tension type headaches?
Peripheral pain mechanism
Central pain mechanism
Describe the peripheral pain mechanism of TTHA.
–Tightness of pericranial myofascial tissues sends nociceptive inputs to the dorsal horn neurons
–Become sensitized – causes what is normally innocuous stimuli to be interpreted as pain
–Central mechanism for episodic TTH (<15 days a month)
Describe the central pain mechanism of TTHA.
–Increased facilitation of cranial structures
–Decreased inhibition of pain transmission at the level of the spinal dorsal horn/trigeminal nucleus
–Altered brainstem reflexes suggest abnormal limbic controlled pain systems
–Mechanism for chronic TTH (>15 days a month)
What is pain above the tentorium referred by?
Trigeminal nerve
Where is pain referred by the trigeminal nerve percieved?
•Pain is perceived in the frontal, temporal and parietal regions of the head
What is pain below the tentorium referred by?
Where is it percieved?
- Pain is referred by the glossopharyngeal, vagus and upper cervical spinal nerve roots
- Pain is perceived in the occipital region
What types of behavior mods can help with TTHA?
- Education about postural mechanics
- Getting correct footwear
- Tension relief exercises
- Stress management/counseling
- Smoking cessation
- Medication
- Ensuring vision is corrected if necessary
What workplace adjustments are helpful for TTHA?
- Computer screen needs to be raised to eye level to promote good posture
- Address chair height!
What are some good tx’s for TTHA?
- Acupuncture
- PT
- OMT
What are the exercises that are useful for TTHA?
- Scapular stabilization
- Trapezius strengthening
- Pectoralis minor stretches
- Sternocleidomastoid and scalene stretches
What is the prodrome period? What are the symptoms?
–Affective or vegetative symptoms 24-48 hrs before
•Euphoria
•Depression
•Irritability
•Food cravings
•Constipation
•Neck stiffness
What is the Aura period? What are the common presentations?
–Seen in a classic migraine
–Visual, auditory, or olfactory hallucinations
•Visual is the most common
–Scotomas are blind spots in the visual field
–Photopsia are dashing lights
–Vertigo
–Paresthesias
What are the symptoms of a migraine headache? What brings relief?
–U/l, throbbing, pulsatile pain
•Can radiate to the opposite side
–Intensity increases over the course of hours
–Nausea, vomiting, diarrhea
–Vertigo/dizziness
–Tremors
–Chills/sweating
–Photo/phonophobia
–Relief
•Lying in a dark room, quiet room
•Sleeping it off
Describe the postdrome period of a migraine HA
–Movement of the head causes pain transiently
–Exhaustion
–Mild elation or euphoria
What are common triggers of migraines?
•May be triggered by:
–Head injury or other trauma
–Emotional stress
–Hormonal stress
•Women are particularly susceptible during menses
–Fasting
–Changes in weather or temperature
–Oversleeping or undersleeping
–Physical stimuli
•Smoking, caffeine or alcohol
–Vasoactive substances in food
•Wine, cheese, cold foods
–Strong odors or lights
•The flicker speed of computers
–Neck pain
When does the initial migraine episode usually present?
•Initial episode most often occurs during puberty
–But can occur at any age between 5-40 yrs
What is the name of CN V?
Trigeminal nerve
What are the projections of CN V?
–3 branches to the face – responsible for the u/l pain
–Meningeal vessels - responsible for vasoconstriction/dilation
–Dura
What is the pathophys of migraines?
•Trigger -> sensitization of CN V nucleus
–Connection unknown
What are cluster headaches a type of?
•Type of trigeminal autonomic cephalgia (TAC)
What are some components of cluster headaches?
- Diagnosis is clinical and unmistakable
- Severe unilateral orbital/supraorbital/temporal pain
- Attack happens at around the same time each day
- Pain lasts 15 min – 3 hrs if untreated
- Average of 8-10 wks/yr
- Hx of at least 5 attacks
- In 50% of pts its onset is nocturnal
- One or more other symptoms of a cluster HA
- No other possible cause of the pain
What are the two theories behind cluster HA?
•Theory 1
–Hypothalamic activation with secondary activation of trigeminal-autonomic reflex
•Theory 2
–Neurogenic inflammation of the wall of the cavernous sinus obliterates venous drainage
–Leads to injury of sympathetic fibers traveling with internal carotid artery
What do you always want to ask someone about who has cluster headaches?
Suicide ideation
Why do you want to do neuroimaging for cluster headaches?
Higher rate of pituitary tumors associated
What is a rebound headache also known as??
Medication overuse headache
What is the diagnostic criteria for rebound headache?
–HA present more than 15 days a month
–Regular use or overuse of pain medication for at least 3 months
–HA developed or worsened with continued use of medication
What are the treatments for rebound headaches?
•Withdrawn the offending medication
–May cause withdrawal symptoms
–HA will get worse for a period of time after removal
•Then it will get better
•Bridge therapy
–Used to get them through the withdrawal period
–Bridging agents
•Naproxen, Tizanidine + NSAID, Glucocorticoids, Ergots, Prochloperazine, Lidocaine, Valproate, Aspirin
•OMT
If you have a chief complaint of a HA the physical exam should include what???
–Cranial nerve screening (II-XII)
–Pronator drift and Rhomberg tests
What are some indications for imaging studies?
•Abnormal or unexplained findings on neurologic exam
•HA that doesn’t fit the clinical picture of any one HA type in particular
•HA in the setting of other diseases
–Ie. Immune deficiency, h/o malignancy, CAD, HTN
•Sudden onset of “worst HA of their lives” or “thunderclap”
–Think aneurysm in the Circle of Willis
•H/o awakening from sleep due to HA
•Rapidly increasing frequency of HAs
•Frontal HA that is worse when leaning forward
–Primarily in children
Describe brain tumor headaches.
–Most often mimics TTH, but can be worse u/l, when bending forward, and/or ax. w/ nausea and vomiting
–48% of brain tumors have HA as a symptom during the course of the disease
In HA treatment, what would we use upper thoracic and rib treatment to accomplish?
Balance autonomic tone
Why do we address cervical dysfunction with OMT for HA?
–Eliminate cervical strain and
soft tissue tension involved in exacerbating
the pain
–Address suboccipital dysfunction
–C1 and C2 can affect the superior cervical ganglion
causing a hypersympathetic tone intracranially
Why would we treat TMJ?
–Eliminate cranial strain patterns affecting the trigeminal neurovascular system
Why treat the abdomen for HA?
–Diaphragmatic restriction affects the sympathetic chain from L2-T5
–Restriction in the mesenteric ganglion can contribute to hypersympathetic tone
Why treat the lumbar, sacrum and pelvis for HA?
–Eliminate compensatory or contributing strain patterns from below
Why is it important to address postural mechanics for HA?
–To reduce exacerbating factors
–Core strengthening, scapular stabilization, proprioceptive training
