Osteopathic approach to headache Flashcards
How are the c-spine vertebrae different than the rest anatomically?
Facet orientation, uncovertebral joints, structure of atlas and axis (think about structure and function here), bifid spinous processes, transverse processes, articular pillars
cervical spine biomechanics review
OA- primary flexion extension, secondary rotation and sidebending
AA- only rotation
Rest- all 3
OA dysfunction- opposite sides, always in F or E
AA- NO sidebending or extension dysfunction! Only rotation
Cervical- Never a Neutral!!!
MET is direct, will always be in opposite of diagnosis.
PRIMARY HEADACHE types
(90%) Tension-type headache, Migraine, Cluster headache Paroxysmal hemicrania.
Secondary Headaches (a long list)
Headache due to infection
including sinusitis, otitis media, dental sepsis, meningitis, brain abscess, encephalitis, other infections
Substance induced headaches
including headache due to medication, substance abuse or substance withdrawal
Headache due to trauma and degenerative causes
including cervical spondylosis, head injury
Headache due to vascular causes
including temporal arteritis, subarachnoid hemorrhage, intracranial hemorrhage, ischemic stroke, transient ischemic attack, venous sinus thrombosis
Headache due to a disorder of homeostasis
including metabolic disturbances, hypertension, hydrocephalus, and exhaustion
Headache due to a disorder of facial or cranial structures
including refractive error, trigeminal neuralgia, temporomandibular joint syndrome , glaucoma
Headache due to non-vascular intracranial causes
including intracranial space occupying lesions, idiopathic intracranial hypertension (pseudotumor cerebri)
Headache due to a psychiatric disorder
including depression, anxiety
HPI for headaches
Onset (acute, subacute/insidious, chronic, intermittent)
Quality (dull, sharp, throbbing, pulsating…)
Location
Intensity (pain scale description)
Associated symptoms (systemic, visual, auditory, vestibular, transient neurologic…)
Timing (frequency, duration)
Exacerbating/ameliorating factors
Prodromes and triggers
Any previous evaluation for similar c/o
Previous treatment (Rx or self administered)
Family history related to headache
Migraine (90% have family members with migraine)
DM or HTN
Sub-arachnoid aneurysm or hemorrhage (4x increased risk)
PMH/Surg Hx/Trauma Hx
Previous headache history (if so include previous work-up and interventions)
Sleep disorders
Disease processes that cause headache (vascular, rheumatologic, etc)
Cervical, cranial or facial trauma, including surgery
Soc/ Meds
Legal or illegal drugs OTC antihistamines Rx drugs with headache side effects Situational stress, abuse Occupational hazards Leisure activities
What kind of headache is this
42 year old female with a history of chronic headache (HA), usually 3/10. Usually starts as a dull ache at the base of the head, slowly moves anteriorly to the right eye and top of head. Accompanied with nausea and abdominal pain when really painful (can get as high as 8/10).
Cervicogenic Cephalgia
Nociception in the head: what does the trigeminal nerve innervate
Sensory Innervates Venous sinuses Nasal sinuses Dural structures Vasculature (MCA) Skin of face and anterior scalp Teeth Pharynx Parts of ear Jaw (except angle)
Nociception in the head: Upper cervical complex (OA, C1-C3)
Innervates Neck Posterior head Posterior cranial fossa meninges Angle of mandible
reflex loops
viscero-somatic (VSR)
visero-visceral (VVR)
Somato-somatic (SSR)
Somato-visceral (SVR)
What kind of reflex is cervicogenic headache?
somatovisceral reflex—the abnormal biomechanical motion (somatic dysfunction) and pain from the upper cervical spine sends nociceptive information to the upper cord via C1 and C2 (and sometimes even as low as C3) rootlets. The upper cord area gets facilitated, irritating the nucleus of cranial nerve 5 (CNV). This irritation will be perceived by the patient as pain in the area of CNV distribution-the head. This is also the mechanism for the nausea, gut pain, and heartburn associated with headache.
It is the close physical relationship and interconnectedness of the central nervous system that makes it so that symptoms that appear to be unrelated may, in fact, be related.
Cervicogenic Cephalgia
A benign headache unrelated to intracranial pressure, infection, hemorrhage or infarct
Begins as a vague ache in the occipital region, base of head or top of neck and slowly spreads to involve the entire head
Associated with somatic dysfunction or spondylosis in the upper cervical region
Discuss vomiting and headache
The vomiting center lies in the medulla oblongata and comprises the reticular formation and the nucleus of the tractus solitarius. When activated, motor pathways descend from this center and trigger vomiting. These efferent pathways travel within the 5th, 7th, 9th, 10th, and 12th cranial nerves to the upper gastrointestinal tract, within vagal and sympathetic nerves to the lower tract, and within spinal nerves to the diaphragm and abdominal muscles.
What kind of headache is this?
9 year old male with a 4 year history of headaches. History is per father; vague pain, points to forehead and top of head usually. Will last for days and then wane, usually coming more in winter, spring and fall (2-3 per month) than summer (1-2 per summer).
PMH: seasonal allergies
ROS: snores, c/o stiff neck a lot, has been to the dentist several times in the last few months for tooth pain without cause found
Chronic Sinusitis
CNV innervates all of the sinuses (and the face)
Mucosa, bones, skin, ligaments, etc)
The sensitivity of the sinuses is through the trigeminal system
Headache
- Sphenoid get vertex headache
- Ethmoid it is between the eyes and the eyes
- The maxilla is at the alveolar ridge (teeth)
Sinusitus and pain
Inflamed sinuses, from whatever source (infection, allergy, trauma, etc.) will send nociceptive information to the trigeminal nerve creating the perception of pain.
The trigeminal nucleus gets facilitated Creating the perception of chronic pain, and increased pain even with lower incoming nociceptive loads.
The facilitation can extend to affect the nuclei of CN 7 creating the sensation of tooth pain in the absence of tooth pathology. Facilitation of CN 9 and 10 create the sensation of nausea. Facilitation of the upper cervical cord will cause increased tissue texture changes (boggy, tight, ropy, warm or cool, tense, etc) and alter biomechanics of the upper cervical spine (suboccipital muscles, paraspinal mm, OA-C2)
What kind of headache is this?
43 year old female with a 6 month history of increasing headache. Always has a dull ache (2/10) in the occipital region which increases to 10/10 pain when she does overhead work. She moved to Maine 4 years ago, has no PCP and has not seen a physician in 6 years.
PMH: weird skin lesion 6 years ago, doesn’t remember the name…needed surgery…
Unintentional 20 lb wt loss over the last 6 months…
And she has been falling a lot and running into things lately…
Malignant melanoma with brain mets
pain from a tumor in the brain…
Brain parenchyma has no pain receptors
Increasing pressure from growing space occupying lesions press on dura
Metabolic chemicals irritate dura
What are headache red flags that require further workup?
Worst" headache ever Change in regular headache pattern (location, duration, assoc sx, etc) First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting that precedes headache Pain induced by bending, lifting, cough Pain that disturbs sleep or presents immediately upon awakening Known systemic illness Onset after age 55 Pain associated with local tenderness, e.g., region of temporal artery
Osteopathic case management of cervicogenic cephalgia
Pharmacological pain management
Osteopathic Manipulative Treatment
Upper cervical vertebral segments (OA, AA, C2)
Suboccipital muscles
Paraspinal muscles
Control of environmental triggers
Habitual postural patterns & postural retraining
Stress and relaxation recognition
Home stretching and strengthening exercises
Osteopathic case management of chronic sinusitis
Control of environmental triggers
Pharmacological mgt (nasal steroid, LT inhibitor), Neti, Decrease exposure
Osteopathic Manipulative Treatment
To address the SD that occurs as a result of central sensitization reflexes
Upper cervical vertebral segments
Cervical soft tissue (inhibition, etc)
To address autonomics to the head (sinuses)
Upper thoracic vertebral segments
Anterior cervical fascia
Lymphatic techniques
Right sided SD of upper thoracics and ribs can affect drainage of the head and neck
Facial effleurage
Osteopathic management of the brain tumor case
MRI
Neurosurgery/oncology referral
No Osteopathic Manipulative Treatment
At least not until fully evaluated
