Primary/Secondary Headache Disorders Flashcards
Primary headaches
have a path-mechanical process not caused by other disease or disorders
secondary headaches
HA caused by other disorders
which types of headaches are primary headaches
migraine and tension type headaches
SNOOP4
- Systemic
- Neurological
- Onset sudden
- Onset after 50 yo
- Pattern change
- Progressive
- Precipitate valsalva
- postural aggravation
- papilledema
red flag history
- history of mechanical trauma
- recent respiratory or GI infection
- Neurological or ischemic symptoms
Red Flag Screening Tests
- Neurological or ischemic signs and symptoms including balance deficit
- Jolt accentuation of HA is a new and less recognized examination –> assesses meningeal irritation
- Lhermitte’s sign
- Vertebral artery test
What is a positive jolt accentuation of HA test?
positive if headache is exacerbated by rotating the head horizontally two or three times per second
Horner’s Syndrome Key Features
- decreased pupil size, ptosis, and decreased sweating on affected side of the face
Migraine Chart
- 4-72 hours
- Unilateral
- Pulsating
- Moderate to severe
- Aggravated by routine PA
- nausea, vomiting, or both
- Photophobia, Phonophobia, or both
- Neck pain is common but does not precede the headache
tension-type Headache Characteristics
- 30 mins to 7 days
- Bilateral
- Pressing or tightening: non-pulsating
- Mild to Moderate
- Not aggravated by routine PA
- No nausea or vomiting
- Either phonophobia or photophobia but not both
- myofacial trigger points commonly present in the pericranial region and C spine
cervicogenic headache characteristics
- variable duration
- unilateral
- dull ache
- mild to moderate
- not aggravated by routine PA
- no nausea or vomiting
- typically no phonophobia or photophobia but in some cases there can be one or the other (not both)
What causes tension type headache?
- peripheral sensitization of nociceptors in myofascial tissue
- increased muscle tenderness (contributory but not necessarily causatory)
chronic TTH
- Occurs > 15 days/month for > 3 months; altered pain sensitivity and central pain modulation
Diagnostic criteria for TTH
A. > 10 episodes fulfilling B-D
B. HA lasting 30 mins to 7 days
C. At least two: bilateral, pressing or tightening (non-pulsating), mild or moderate, not aggravated by routine PA
D. No nausea or vomiting, not greater than 1 photophobia or phonophobia
E. Not better accounted for by something else
Acute management of TTH
analgesic medication or analgesic plus caffeine, muscle relaxers
Preventative management of TTH
tricyclic antidepressants, beta blockers, Divalproex sodium
TrP injections for TTH
typically uses lidocaine and bupivacaine
manual therapy for TTH
- trust and non-thrust spinal mobilization and manipulation
- mobilization with movement
- STM/IASTM
- Dry needling
- etc
exercise and education for TTH
- posture and ergonomic adjustment
- stretching
- postural strengthening
- neural mobilization exercises
what is/what causes migraine headaches?
- stimulation of peripheral afferents in the trigeminocervical complex
- pathophysiology is complex and unclear but may have genetic abnormalities that increase CNS excitability
things included in trigeminocervical complex
all branches of CNV, posterior dura, C1 and C2 dermatomes
Premonitory: 2-48 hours before migraine
neck pain, fatigue, yawning, impaired concentration, mood changes, food cravings, increased urinary frequency, irritability, nausea and difficulty sleeping
migraine attack: 4-72 hours
- pain (typically throbbing), nausea, vomiting, photophobia, phonophobia, anxiety, hyperosmia, depressed mood, neck pain and stiffness, insomnia
postdrome: hours to days
- tiredness, head and neck soreness, decreased cognition, mood change
- mechanism less understood
Prodrome
thought to be due to hypothalamic activation
aura
thought to be due to cortical spreading depolarization which often begins in visual cortex
HA pain
vasodilation and/or dural swelling thought to be due to release of neurotransmitters such as substance P, neurokinin A, and CGRP
calcitonin gene related peptide
- A neuropeptide found in the CNS and PNS that has pain-signaling and vasodilator functions
- In MH it is thought to contribute to dural meningeal inflammation
Diagnostic criteria for migraine without aura
A. > 5 attacks fulfilling B-D
B. HA lasting 4-72 hours (treated or untreated)
C. At least two: unilateral location, pulsating, moderate or severe, aggravated by (or causes avoidance of) routing physical activity
D. During attack, at least 1: nausea and/or vomiting or photophobia and phonophobia
E. Not better accounted for by something else
migraines are different because of …
- Lasting 4 to 72 hours
- Unilateral location
- Pulsating quality
- Moderate to severe intensity
- Aggravated by physical activity
- Associations with nausea, vomiting, phonophobia, or photophobia
Acute medical management of migraine headache
- Ergot alkaloids
- Triptans
Ergot alkaloids
- similar MOA as triptans but not as selective
- higher incidence of adverse effects
triptans
- selective serotonin receptor agonists
- vasoconstriction of distended extracerebral vessels
- inhibits vasoactive neuropeptides
- inhibits nociceptive NTs
What do abortive migraine headache medications do?
- stop a migraine attack as its happening
- take as soon as possible (within 30 mins of onset)
What is the first line abortive treatment for mod to severe migraine
Triptans
- less effective in pts with prolonged and severe migraine
medication overuse headache
1/2 of pts with chronic headache have MOH
- triptans should not be used > 10 days/month
Other prophylactic medications for MH
- CGRP Receptor Antagonists
- Anticonvulsants
- Botox (31 sites)
Headache management strategies
- management of HA triggers
- Medical management often multidisciplinary
- Management of associated symptoms
- management of MSK impairments
- exercise considerations
Management of headache triggers
- dehydration, fasting, alcohol, cured meats, aged cheese, citrus, chocolate, caffeine, wine, high sodium, MSG
- poor sleepy hygiene and quality
- stress
management of associated symptoms
- reduced lighting or dark room
- altered lighting source
- blue light screen filters or glasses
- dry eye control
- noise cancelling headphones or earplugs
exercise for for migraine headaches
- altered cervical muscle motor control
- stretching
-aerobic exercise
aerobic exercise prescription for migraine headaches
- 40-60 minutes of exercise 2-3 times per week with 15-30 mins of aerobic exercise
- BRPE 14-16/20 or 70% HRmax but not >150 bpm
dietary supplements for migraine prevention
- magnesium (400-800mg)
- Riboflavin (400 mg)
- Coenzyme Q10 (300 mg)
cause of cervicogenic headache
- convergence of cervical (C1-C3) and trigeminal afferents in the brainstem and spinal cord (C1-C4)
- high incidence post WAD
What are the two muscles that can have bilateral myofascial pain from only one side
SCM and trap
diagnostic criteria for cervicogenic headache
A. Any headache fulfilling C
B. Clinical and/or imaging evidence of Cx spine disorder or soft tissues of the neck known to cause HA
C. evidence of cessation by at least 2: Ha developed in temporal relation to onset of Cx disorder, HA significantly improved or resolved in parallel with improvement in Cx disorder, reduced Cx ROM and HA worsened with provocative maneuvers, HA abolished with diagnostic block
D. Not better explained by something else
major criteria for CGH
- SxS of Cx involvement
- precipitation of HA by neck movement and/or sustained awkward positioning and/or external pressure on ipsilateral upper Cx or occipital region
- restriction of Cx ROM
- ipsilateral neck, shoulder, or arm pain
other characteristics of CGH
- mod- severe, non-throbbing, non-lancinating pain typically starting in the neck
- marginal effects of indomethacin, ergotomines, tripans
- can have photophobia, phonophobia or nausea but not as marked as MH
what is the gold standard care for cervicogenic headache?
physical therapy
what is the gold standard care for migraine
pharmacologic
medical management of CGH
- PT
- analgesics
- peripheral nerve blocks of greater and lesser occipital nerves
- TrP injections
Cervical Flexion/Rotation Test
- normal rotation is about 45 degrees each way
- positive test is reproduction of symptoms or loss of range >10 degrees
- Dr P says less than 26 is bad
Examination of HA - Migraine
+ TrP
+ Limited C1-C2 Rot
- Impaired CFRT
Examination of HA - TTH
+ TrP
- Limited C1-C2 Rot
- impaired CFRT
Examination of HA - CGH
+ TrP
+ Limited C1-C2 rot
+ Impaired CFRT
