Systemic tx class 1 (headaches) Flashcards
systems approach to care
Bio-psycho-social (BPS)
Think systems, as in physiology, not just anatomy
Patient centred care
Therapeutic relationship
“more lifelike approach”
The enemy of individualized care is protocol and routine…
Each case is context dependent
There are multiple answers, so can you justify and defend your position?
case management steps
Rule out red flags.
Modify.
Treatment goals-what can you do to increase the quality of life of your patient.
Indications for your treatment choices
Case management
Rule out red flags.
Modify.
1) Rule out red flags-red flags require further investigation (we first need to know what they are)
Can we treat safely today?
*if no, when do we refer out
(is it a medical emergency)
*if yes, what modifications are needed for safety
What can we modify?
HOPNMRS is one tool to rule out and treat safely
(This class will emphasize history questions!)
Treatment goals-what can you do to increase the quality of life of your patient.
Indications for your treatment choices
2) Treatment focus-treat effectively
Goals
-consider the client’s goals, short and long term (this is where our goals come from) -look at ‘contributing factors’ rather than cause. Often we don’t fully know the cause, and can be multifactorial. -management of chronic conditions=complex
treatment focus
Treatment focus
-think systemically, engagement, interaction, and what can you affect? -treatments include assessment-reassassment/homecare/education, not just hands on. -goal to increase the quality of life for our patients
WE ARE NOT FIXING OUR CLIENTS CONDITIONS
Case Management
History questions to rule out red flags, determine health status, establish goals and expectations
Assess-Special tests to confirm, and direct treatment
Goals-based on client’s story
Techniques-determine what is indicated based on goals/symptoms
Homecare/hydro-relevant to patient goals/symptoms
primary vs secondary headache
Primary –is the condition
Secondary-underlying condition
three types of (primary) headaches
Tension
Migraine
Cluster
E.g. of underlying conditions in secondary headaches
Organic -Exertion -Withdrawal/Rebound
Rebound -Allergy -Meningitis
TMJD -Cervicogenic -Cold/Flu
Exertion -TMJD -Organic (tumour)
Allergy -Trauma -Sinus
note about severity of pain (similar to OA & other orthopedic conditions)
in headache as well
Severity of pain is not an accurate indicator of severity of condition
about tension HA
Bilat px
Diffuse px
Band like px around head
Dull or vice like
Onset later in day
Last 30 min to weeks
Mm stiffness, hypertoned mm, tinnitus
These HA begin in adulthood
Affect both men and women
Primary HA-cause unclear
Contributing factors:
Stress, poor ergonomics or posture,
Family hx, trigger points in neck or head, cold, hypoglycemia, fatigue
Cervicogenic possible co-relationship
about Migraine HA
Unilateral
Px starts as dull ache then becomes intense and pounding, has 3 phases, and triggers
Last 4-72 hours
May have aura or visual disturbances
Nausea, vomiting, photophobia, phonophobia,
migraine demographics
Family hx 70%
Women more than men
Starts around first menses
May start again near perimenopause
primary migraine HA
Primary HA-cause unclear, vascular/neuro?
primary migraine HA – TRIGGERS
Triggers: hunger, stress, allergies, meds, weather, visual/auditory/ olfactory stimuli, sleep, hormones.
CLUSTER HA
Unilat px
Intense severe px
Intermittent px
(daily, repeating for weeks/months)
Often nocturnal (waking up with HA)
cluster HA demogrpahics
Affect only 0.1% of people
Men 5x more likely
cluster headache contributing factors
Smoking is a risk factor
Association with abnormal hypothalamic function
primary cluster HA?
cause unclear
trauma headache
Pain in the head or neck from injury
As a result of trauma – anyone
trauma headache etiology
Trauma to the head, neck or spine. Falls on tailbone may create headache due to dural tube and meninges tension
sinus HA
Pain in face- forehead, maxilla, btw eyes
Nasal drip or congestion
Pain increases in different positions
Facial tenderness
sinus HA – demographics
Anyone experiencing upper respiratory issues
sinus HA – etiology
Viral, bacterial infections, allergies, hx of facial trauma, abcesses in molars
withdrawal headache
Begin in early am when blood levels of drug are lower
Throbbing px
Bilateral px
withdrawal HA – demographics
Anyone experiencing medication/drug withdrawal
withdrawal HA – etiology
Removal of caffeine, drugs or medications
migraines
Most commonly no aura (visual disturbance)
Migraines may have 3 phases
THREE PHASES OF MIGRAINE
PRODROMAL
-mood changes, cravings, cold (may have aura-visual, confusion, slurred speech)
ATTACK
-unilateral, throbbing, sensitive to light and noise, nausea, vomiting
POSTDROMAL
-tired, sluggish, flaring pain during quick movement
FOUR CONDITIONS w/ HA when pt must be referred out
*Temporal arteritis -rare condition affecting elderly. Inflammation of the temporal artery. Throbbing at temple, may appear red and swollen. Refer to doctor within 24 hours.
*Preeclampsia-HA in pregnancy-especially if severe. Immediate doctor referral.
*Aneurism-sudden, severe, explosive(like lightning) –Immediate referral to doctor
*Meningitis-fever, stiff neck (+Koernig’s) Immediate referral to doctor
Koernig’s sign test
Kernig’s sign is a physical exam used to assess for meningitis, an inflammation of the membranes around the brain and spinal cord:
The patient lies on their back with their hips and knees bent at a 90-degree angle.
The examiner then slowly extends one knee at a time.
A positive Kernig’s sign is indicated by pain, resistance, or an inability to extend the knee.
“Extension of the leg while performing Kernig’s sign stretches the hamstring, which pulls on the surrounding tissue near the inflamed spinal canal and meninges.”
RED FLAGS FOR HEADACHES
—> INCORPORATE INTO Hx Q
Severe pain that comes on suddenly
Head pain accompanied by fever
Headache with nausea, and/or vomiting
Head pain that worsens over time, especially if it follows a head injury (also- recent head injury)
Accompanied by mental confusion, seizures, mood swings, or other neurological symptoms (memory loss, double vision, loss of motor control/coordination,/strength, affects special senses)
HA that occurs after physical activity, straining or coughing
New headache after the age of 55
(—> or in early childhood)
HA’s accompanied by numbness on one side of the face/head
(pins/needles in case study)
HA’s accompanied by clear fluid or blood coming out of ears
HA’s that do not fit a recognizable, usual pattern of s&s to the person –unusual presentation
New HA in a person with a history of cancer or heart disease
CURRENT HA WILL NEED TREATMENT MODIFICATIONS
TREATMENT MODIFICATIONS FOR ACTIVE HA
Less physical assessment during active HA (more time on history to rule out red flags)
Modify position-supine or sidelying, check if client can tolerate prone (level of HA on scale)
Techniques-during active HA, ask if ok to touch/work directly on head
Limit strokes toward head (BLOODFLOW TOWARDS THROBBING/PAINFUL ACUTE AREA)
Less TPR and pressure during active HA
(RATTRAY ALSO SAYS NOT TOO DEEP W/ PRESSURE)
Aware of triggers in room-lights/noise
E.g. of longterm vs shortterm goals for HA
reduce current discomfort
= short-term
reduce frequency of HA
= long term
–> E.g. via change in habits, or reducing/removing stressful triggers
TREATMENT IN BETWEEN HA
Decrease TPs (where is usual pain?)
—> E.g. SCM
Decrease stress response/feedback loop (SNS)
Consider habitual postures ie. Head forward
—> HOMECARE for posture
Consider areas with lack of movement (TENSION)
Education-patient self management tools
—-> Diaphragmatic breathing, movement, stretch, hydro
ALSO CONSIDER ISOMETRICS FOR NECK (see Rattray)
finding ways to decrease “fid” of HA
removing/reducing triggers
changing habits (including sleep, exercise)
etc.
cluster HA
“Extreme sharp or stabbing pain, usually in, behind or around one eye. The pain can spread to other areas of the face, head and neck. Pain on one side of the head in a single cluster. Pain can switch to the other side in another cluster.”
“The symptoms of a cluster headache include stabbing severe pain behind or above one eye or in the temple.”
THREE “levels” for Hx Qs
Level 1-safety/rule out/investigate red flags
Level 2-Treatment and type of HA
Level 3-Contributing factors
Level 1-safety/rule out/investigate red flags
-HA now, neuro symptoms, intense pain with sudden onset, Dr, Meds, trauma, fever, underlying health, new H/A in young/old, unusual
Level 2-Treatment and type of HA
-where is the pain, when, FIDs of HA, stress level, triggers, other tx (eyes, dentist, chiro)
Level 3-Contributing factors
-lifestyle: sleep, work, family hx, activity level
valuable special tests during Dx/Ax of HA
1) Cervical compression/distraction
(tests for nerve root or facet joint irritation)
—> POSITIVE: radiating pain or other neurological signs in affected arm indicates compression of a cervical nerve root
POSITIVE: pain in the neck/shoulder indicates cervical facet joint irritation
1)Cervical compression/distraction
(tests for nerve root or facet joint irritation)
—> POSITIVE: radiating pain or other neurological signs in affected arm indicates compression of a cervical nerve root
POSITIVE: pain in the neck/shoulder indicates cervical facet joint irritation
DISTRACTION:
reduction of SSx = positive
2) Spurling’s Test / “Quadrant”
(tests for cervical nerve root, facet joint irritation)
Unaffected side first!
Seated; extend, side bend & rotate
Carefully apply compression downward
POSITIVE: pain radiates down into the arm on that side
Repeat on other side
3) Vertebral Artery Test (VAT)
(Tests for circulation deficiency of the vertebral artery at the transverse foramen)
Patient is supine; therapist seated by guest’s head
Patient has eyeglasses off (if applicable); asked to keep eyes open
Passively fully extend the head and neck, side flexion, then fully rotate to the same side, hold for 30 seconds
Repeat on other side
POSITIVE: vertigo, nausea, nystagmus – do not perform further testing if positive
signs and symptoms which may indicate possible vertebral-basilar artery problems (from Magee)
o Malaise
o Nausea
o Vomiting
o Dizziness/vertigo
o Unsteadiness in walking, incoordination
o Visual disturbances
o Severe headache
o Weakness in extremities
o Sensory changes in face or body
o Dysarthria (speech)
o Dysphagia (swallowing)
o Disorientation, light headedness
o Hearing difficulties
o Facial paralysis
4) Kernig’s sign test
noted in previous card
5) Soto Hall test
Patient is supine on the table
Ask the patient to place their hands behind their head and flex their chin to their chest
If the patient experiences a sharp pain down the posterior neck and spine this may indicate meningitis
rebound headaches (withdrawal HA)
“Rebound headaches: also called analgesic or painkiller rebound, caffeine withdrawal, and holiday, weekend or travel headaches, (they) are classified as vascular headaches, but are much less intense than a migraine, cluster, and sensitivity headaches. Characterized by dull throbbing pain on both sides of the head, these headaches strike when you miss your daily medication or caffeine.”
“… over-consumption of or withdrawal from narcotics or caffeine-containing substances (etc.)…constrict blood vessels, and the subsequent “rebound” dilation can trigger a headache.
“…Rebound headaches are best treated by gradually removing the rebound-causing substance and by whole natural body detoxification.” (p. 59).
