Lecture 9: Osteopathic Approach to Head Pain

Question 1

What nerves should be considered for head pain of anterior 2/3 vs. posterior 1/3?

Answer 1

• Anterior 2/3 –> Trigeminal n.
• Posterior 1/3 –> Lesser Occipital (C1-3), Recurrent branches of IX and X

Question 2

Relevant sympathetic spinal levels associated with head pain?

Answer 2

T1-T4

Question 3

Mean age of onset for tension HA?

Peak prevalence?

Answer 3

• MAO = 25-30 yo
• Peak prevalence = 30-39 yo

Question 4

Anxiety and depression often associated w/ what type of headache?

Answer 4

Chronic tension-type HA

Question 5

Peripheral pain mechanisms are more likely important for what type of tension HA?

Answer 5

Episodic tension-type HA

Question 6

Central pain mechanisms are more likely involved in what type of tension HA?

Answer 6

Chronic tension-type HA

Question 7

What are the clinical features (signs/sx’s) of Tension-type HA’s?

Answer 7

• Bilateral
• Mild to moderate intensity
• Pressure or tightening quality (nonpulsating)
• Absence of N/V
• Not aggravated by routine physical activity

Question 8

How long can Episodic Tension HA’s last?

Answer 8

30 minutes to 7 days

Question 9

Chronic Tension HA’s are defined as having episodes for how long (days/months)?

Answer 9

≥ 15 days/month on average for ≥ 3 months

Question 10

What is the most common abnormal PE finding for Tension HA’s?

Answer 10

Pericranial muscle tenderness - tends to be mostly scalp

Question 11

How to treat the neurological component (5-models) of a tension-type HA?

Answer 11

• Analgesics and NSAIDs = 1st line
• Combination analgesics w/ caffeine = 2nd line
• Metaclopramide

Question 12

3 focuses for the Metabolic component (5-models) in tx of Tension-HA?

Answer 12

• Sleep hygiene
• Hormonal influences - menstrual
• Hydration

Question 13

Using the 5-models what component should be addressed first in the treatment of Migraine, Cervicogenic, and Tension HA’s?

Answer 13

• Respiratory/circulatory
• Address lymphatics first to reduce irritants from inflammatory milieu

Question 14

Using the 5-models approach what should be addressed via the neurological component for Migraine, Cervicogenic, and Tension HA’s?

Answer 14

• Address counterstrain points anteriorly and posteriorly in the cervicals, upper thoracics, upper ribs, and UE’s
• Use cranial to address other contributing SD’s

Question 15

Which treatment technique for SD’s has been shown to be an effective method for treating tension HA?

Answer 15

MFR

Question 16

How does a menstrual migraine differ than a normal one?

Answer 16

Typically w/o aura and more severe

Question 17

Using the 5-models approach what should be addressed via the Biomechanical component for Tension HA’s?

Answer 17

• Address myofascial SD’s
• Address joint SD’s w/ cranial, MET, Still’s, HVLA, or FPR

Question 18

What are 2 likely risk factors for Migraines?

Answer 18

1. Medication overuse
2. MS

Question 19

What is the mnemonic used for Migraine Diagnosis?

Answer 19

• POUND
• Pulsating
• Duration 4-72 hOurs
• Unilateral
• Nausea or vomiting
• Disabling

*4/5 criteria met has + likelihood ration 24 for definitive possible migraine

Question 20

Differential Diagnoses for Migraines?

Answer 20

• Tension HA or Cluster HA
• Cervical spine dz –> greater occipital neuralgia
• Acute cervical strain –> Whiplash
• Intracranial mass or Meningitis or Subarachnoid hemorrhage or TIA
• Sinusitis
• Cavernous sinus thrombosis
• Optic neuritis or Acute Glaucoma
• SLE
• TMD
• Epilepsy

Question 21

What is pathognomonic for migraine w/ aura?

Answer 21

Spreading oligemia (reduced blood volume) in brain

Question 22

Migraine w/o aura seems to be associated with what messenger molecules?

Answer 22

• NO
• 5-HT
• CGRP

Question 23

Using the 5-models how do you treat the Biomechanical components of Migraines?

Answer 23

Address joint SD with Cranial, MET, Still’s, HVLA or FPR

Question 24

Cervicogenic HA is caused by disorder of what?

Answer 24

Cervical spine and its component bony, joint, and/or soft tissue elements

*Usually NOT associated w/ neck pain

Question 25

Involvement of which cervical facet is the most frequent source of Cervivogenic HA?

Answer 25

• C2-C3 = most frequent
• AA is probably 2nd

Question 26

Facet pain from C5-C6 and C6-C7 may contribute to what type of relfex resulting in TrP pain referral to the head?

Answer 26

Somato-somatic reflex

Question 27

For diagnosis of Cervicogenic HA, evidence of causation by at least two of the following 4 items must be met?

Answer 27

1. Developed in temporal relation to the onset of cervical disorder/lesion
2. Significantly improved or resolved w/ improvement in or resolution of cervical disorder/lesion
3. Cervical ROM is reduced AND HA is made significantly worse by provocative maneuvers
4. Abolished following diagnostic blockade of a cervical structure or its nerve supply

Question 28

What are 5 differential diagnoses for Cervicogenic HA?

Answer 28

1. Migraine - POUND
2. Tension HA
3. C2 neuralgia
4. Neck-tongue syndrome
5. Occipital Neuralgia

Question 29

If the pain associated with a HA is myofascial what category does it best fit under?

Answer 29

Tension HA

Question 30

What are the common signs/sx’s of C2 neuralgia?

Answer 30

• Paroxysmal sharp or shock-like pain centered in occipital region
• Ipsilateral eye lacrimation and conjunctival injection are common

Question 31

What is Neck-tongue syndrome?

Onset typicall when?

Answer 31

• Rapid head turning causes subluxation of the posterior AA joint and C2 spinal root compression
• Sx = neck pain, may be asscociated w/ ipsilateral tongue sensory sx’s
• Onset typically during childhood or adolescence

Question 32

Using the 5-model approach how should the Biomechanical component of Cervicogenic HA’s be treated?

Answer 32

• Address joint SD w/ MET, Stills, or FPR
• HVLA may irritate facilitated segments!