Review: OAT Head Pain Flashcards
PE components in osteopathic approach to head pain
HEENT
Neuro (including muscle strength, CNs, DTRs)
OSE (flexion, extension, traction, and compression of cervical spine)
Psychological disposition
Special tests as indicated
Areas of possible TART or lymphatic findings in PE for head pain
Cranial Cervical Upper thoracic Upper ribs Upper extremities Sacrum Posture/leg length
Osteopathic considerations in terms of location of head pain as well as possible sympathetic involvement
Anterior 2/3 = trigeminal n.
Posterior 1/3 = lesser occipital (C1-3), recurrent branches of IX and X
Sympathetics: T1-4
Epidemiology of tension headache
Mean age at onset 25-30
Peak prevalence at age 30-39
Female to male ratio 5:4
30-78% mean lifetime prevalence of tension type headache globally
Risk factors for tension headache and associated conditions
Likely: Stress, mental tension, emotional disturbance
Possible: poor self-rated health, inability to relax after work, sleeping few hours per night
Associated: anxiety, depression, migraine +/- aura, medication overuse headache
Tension HA causes
Uncertain cause; susceptibility influenced by genetic factors in epidemiological and twin studies
Tension HA pathogenesis proposed
Active myofascial trigger points in head, neck, and shoulder
Episodic tension-type headache: peripheral pain mechanisms likely more important
Chronic tension type headache: central pain mechanisms more likely involved
Clinical features of tension type HA
Bilateral, mild to moderate intensity, pressing or tightening quality (nonpulsating)
Not aggravated by routine physical activity
No N/V; may have photophobia or phonophobia but not both
May increase in frequency or duration over time
Difference between episodic tension HA and chronic tension HA
Episodic: HA can last 30 minutes to 7 days; infrequent with less than 10 episodes occurring on less than 1 day per month over the course of a year; or can be frequent with greater than 10 episodes on 1-14 days per month for greater than 3 months; often develops into chronic type
Chronic: episodes on more than 15 days per month on average for more than 3 months; may be continuous and unremitting, pts with chronic type more likely to seek care
Most common abnormal HEENT finding with tension headache
Pericranial muscle tenderness — tends to be mostly the scalp
Can also have dysfunction of frontal, temporal, masseter, pterygoid, SCM, splenius, and trapezius mm. (More likely with episodic than chronic)
General 5 models for tension HA tx
Behavioral: identify triggers, encourage following prescriptions, biofeedback, CBT and relaxation, counseling
Neurologic: analgesics and NSAIDs, caffiene, metaclopramide
Biomechanical: PT and acupuncture, OMT/manual therapy level 2, intra-oral appliance
Metabolic: sleep hygiene, hormonal influences, hydration
Respiratory-circulatory: hydration
5 models OMT for tension headache
Biomechanical: address myofascial SDs, address joint SDs with cranial, MET, Still’s, HVLA, or FPR
Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu
Neuro: address counterstrain points in cervicals, upper thoracics, upper ribs, and upper extremities; use cranial to address other SDs
Metabolic: improvement is d/t other approaches
Behavioral: exercise Rx to support tx of SDs contributing symptoms
One study showed that _______ (osteopathic technique) is more effective than control intervention for tension HA
MFR
Epidemiology of migraine
Currently about 15% of adults; 21% of US females and 10% of US males
Most common in american indian or alaska native > white > black or african american > hispanic or latino > native hawaiian or pacific islander > asian
Risk factors for migraine
Analgesic overuse (defined as daily or almost daily for over 1 month)
MS
Possibly oral contraceptives
Migraine associated conditions
Tension HA
Episodic syndromes: recurrent GI disturbance, vestibular migraine, benign paroxysmal torticollis
Migraine during pregnancy: preeclampsia, vascular dx (stroke, MI, PE, HTN, DM, smoking)
Endometriosis, obesity, depression, pain conditions, syncope, meniere’s disease
POUND mnemonic for migraine dx
Pulsating
4-72 hOurs duration
Unilateral
Nausea or vomiting
Disabling
[4-5 criteria = likely a migraine]
Precipitating factors for migraine
Menses, diet, fasting, stress, stress let-down, exertion, altered sleep, visual stimuli, odors, smoking, alcohol, caffeine withdrawal, oral contraceptives, vasodilators, change in weather
Differential dx for migraine
Tension HA, cervical spine dz (greater occipital neuralgia), acute cervical strain, intracranial mass, meningitis, subarachnoid hemorrhage, TIA, cluster HA, cavernous sinus thrombosis, optic neuritis, acute glaucoma, pseudotumor cerebri, SLE, cervical a. dissection, TMD, epilepsy, sinusitis
Migraine pathogenesis
With aura: spreading oligemia (reduced blood volume) in brain
Without aura is uncertain
No longer considered vascular based phenomena in terms of arterial constriction/dilation
Intracranial pain sensitive structures are meninges and intracranial blood vessels
May also be associated with spreading suppression of initial neuronal activation and increased occipital cortex oxygenation as well as dorsal pontine activation
General 5 models for migraine tx
Behavioral: bed rest, identify triggers, encourage following prescription, biofeedback, CBT and relaxation, aerobic exercise and yoga, counseling
Neuro: analgesics and NSAIDs, triptans for moderate to severe, metaclopramide, prophylactic meds like TCAs
Biomechanical: PT and accupuncture, OMT manual therapy level 2
Metabolic: sleep hygiene, hormonal influences - menstrual, hydration
Resp/circ: prophylactic meds: beta blockers, hydration
5 models OMT considerations for migraine
Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu
Biomechanical: address joint SDs with cranial, MET, Still’s, HVLA, or FPR
Neuro: address counterstrain points in cervicals, upper thoracic, upper ribs, upper extremities
Metabolic: improvement d/t other approaches
Behavioral: exercise Rx to support tx of SDs contributing to sxs
Type of headache caused by disorder of cervical spine and its component bone, joint, and/or soft tissue elements, usually but not invariable accompanied by neck pain
Cervicogenic HA
IHS dx of cervicogenic HA
A. Any HA fulfilling criterion C
B. Clinical and/or imaging evidence of disorder or lesion within cervical spine or soft tissues of neck known to be able to cause HA
C. Evidence of causation demonstrated by 2 of the following: developed in temporal relation to onset of cervical disorder/lesion, significantly improved or resolved with improvement in cervical disorder/lesion, cervical range of motion is reduced AND HA is made significantly worse by provocative maneuvers, abolished following diagnostic blockade of cervical structure or its nerve supply
D. Not better accounted for by another ICHD-3 dx
DDX for cervicogenic HA
Migraine
Tension HA
C2 neuralgia
Neck-tongue syndrome (rapid head turning causes subluxation of posterior AA and C2 spinal root compression —> neck pain, occipital pain, ipsilateral tongue sensory symptoms, onset is typically during childhood or adolescence
Occipital neuralgia
General 5 models tx for cervicogenic HA
Behavioral: no data; exercise Rx to enhance OMT
Neuro: pregabalin, anesthetic blockade, radiofrequency block
Biomechanical: PT and accupuncture, OMT, surgery
Metabolic: glucocorticoid injection
Resp/circ: no data, hydration
5 models OMT considerations for cervicogenic HA tx
Resp/circ: address lymphatics first to reduce irritants from inflammatory milieu
Biomechanical: address joint SDs with MET, Still’s, or FPR; HVLA may irritate facilitated segments
Neurologic: address anterior and posterior counterstrain points
Metabolic: improvement d/t other approaches
Behavioral: exercise Rx
