headaches

Question 1

Migraine
o With aura
o Without aura
* Tension-Type Headaches
* Cluster Headache

Answer 1

Primary Headaches

Question 2

o Trauma or injury to head or neck
o Cranial or vascular nerve disorders
o Non-vascular intracranial disorders
o Reactions to substance or its withdrawal
o Infection
o Disorders of homeostasis
o Disorders of cranium, neck, eyes, ears, nose, sinuses,
teeth, mouth, or other facial or cervical structures
o Psychiatric disorders
o Other cranial neuropathies or facial pain

Answer 2

Secondary Headaches

Question 3

Trauma or injury to head or neck

Disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structures

other cranial neuropathies

Answer 3

Secondary Headaches that we will probably treat

trauma
* Headache must present with 7 days following trauma
* i.e.Postconcussion headache

disorders
* TMD
* Cervicogenic headache

other cranial neuropathies
* Trigeminal neuralgia
* Occipital neuralgia

Question 4

A . At least 5 attacks fulfilling criteria B-D:
B. Headache lasting 4-72h
(untreated/unsuccessfully treated)
C. Headache has ≥
2 of the following:
* Located unilaterally
* Pulsating quality
* Moderate to severe intensity
* Aggravated by or results in avoidance of routine physical activities
D. During the headache, at least 1
following is present:
* Nausea or vomiting
* Photophobia
* Phonophobia

Answer 4

Migraine requirements

Question 5

aura

Answer 5

refers to fully reversible symptoms affecting
the following:
o Typical: visual, sensory, speech and/or language
systems
o Atypical:
▪ Motor weakness (can sometimes last days
to weeks)
▪ Brainstem: dysarthria, vertigo, tinnitus,
diplopia, ataxia, reduced consciousness
▪ Retinal: monocular field defect/blindness

• Aura symptoms last 5-60 minutes
• Aura is accompanied by or followed in <60 min by a
  headache

Question 6

Aura symptoms last

Answer 6

5-60 minutes

Question 7

TENSION HEADACHE

Answer 7

Peripheral pain mechanisms
(Infrequent and frequent type)

Central pain mechanisms
(chronic)

Question 8

• Causes:
  Peripheral pain mechanisms
  (Infrequent and frequent type)
  Central pain mechanisms
  (chronic)
• Classifications:
  Infrequent episodic tension-type
  headache (<1 day/month)

Frequent episodic tension-type
headache (1-14 days/month)

Chronic tension-type headache
(≥15 days/month for >3 months)

Answer 8

Tension headaches

Question 9

• Duration: 30 min to 7 days
• At least 2 of the following:
  Bilateral location
  Pressing or tightening quality
  Mild or moderate intensity
  Not aggravated by routine physical activity
• Both of the following:
  No nausea or vomiting
  No more than one of
  photophobia or phonophobia

Answer 9

Tension Headaches

Question 10

Severe unilateral orbital,
supraorbital, and/or temporal
pain with:

Answer 10

▪ At least one
: ipsilateral lacrimation, nasal congestion, eyelid edema, facial sweating, miosis/ptosis
▪ Sense of restlessness or agitation

Duration: 15-180 min in “clusters” for weeks to months

Cause unknown, but thought to be due to:
▪ Histamine or serotonin release near the trigeminal nerve
▪ Hypothalamus dysfunction

Question 11

Cough headache
Exercise headache
Associated with sexual activity
Thunderclap headache (possibly due to vascular)
Cold-stimulus headache (brain freeze)
External pressure headache
Primary stabbing headache
New daily persistent headache (NDPH)

Answer 11

OTHER
PRIMARY
HEADACHES

Question 12

a symptom of a disease or condition that can activate the pain-sensitive nerves of the head

Answer 12

Secondary Headaches

Question 13

Location: unilateral jaw, face, and/or temple

Presents with concurrent TMD symptoms:
* Pain precipitated by jaw movements and/or chewing
* Reduced or irregular jaw opening
* Noise from one or both TMJs with jaw movements
* Tenderness of joint capsule(s) of one or both TMJs

Answer 13

TMD headache

Question 14

• Ram’s horn pattern
• Clinical or imaging evidence of
  disorder or lesion within cervical
  spine or soft tissues of the neck
• Must demonstrate at least 2 of the following:

Temporal relationship to onset of cervical disorder/lesion

Significant improvement/resolution parallel to improvement/resolution of cervical disorder/lesion

Reduced cervical ROM with headache reproduction

Headache abolished by cervical block

Answer 14

Cervicogenic Headache

Question 15

• AROM/PROM: expect limited with sidebend and rotation to side of headache with firm end feel
  due to increased tissue tension and/or joint mobility restrictions
• Reduced strength through postural musculature
• Limited in AA rotation (cervical flexion w/ rotation) unilaterally with firm end feel
• Limited OA nodding mobility with firm end feel
• Lateral glides may also be restricted upper>lower cervical
• Tissue tone/TrPs/pain reproduction most often noted unilaterally at:
  o Suboccipitals, SCM, scalenes
• Reduced strength through longus colli – may cause HA reproduction with testing
• Deepneck flexor endurance test
• Normative values are variable, but ~40s males, ~30s females

Answer 15

Cervicogenic headache objective

Question 16

Cause: Due to impingement of trigger points at branches of neural pathway

Occipital neuralgia (A)
* Unilateral or bilateral scalp pain

Trigeminal neuralgia (B)
* Unilateral facial pain

Answer 16

CRANIAL NEUROPATHIES/FACIAL PAIN

Question 17

Headache Red Flags

SNOOP4

Answer 17

Systemic
Neuropathies Not resolving/New
Onset sudden
Older age x > 50 (most likely secondary cause/illness
Progression
Papilledema (swelling of optic nerve)
Positional/Precipitated by Valsalva maneuver
Pregnancy / new onset during

Question 18

o Team approach: medications for prevention and break through headaches
o Education in triggers and management
o Treat associated cervicothoracic dysfunction
o Stress reduction techniques/meditation

Answer 18

Migraine treatment (primary headache)

Question 19

o Treat cervicothoracic dysfunction
o Postural exercises
o Stress reduction techniques/meditation
o Potential OTC medications or referral to MD if uncontrolled

Answer 19

Tension Headache treatment (primary headache)

Question 20

TREATMENT:
SECONDARY HEADACHES

Answer 20

Cervicogenic: neck
▪ Most often stiff C0-3
▪ Suboccipital tone
▪ SCM tone and trigger points
▪ Postural stability

Neuralgias:
soft tissue impeding nerve

TMD headache: TMJ
▪ STM muscles of mastication
▪ Joint mobilization neck and TMJ
▪ Postural stability

Question 21

• Manual therapy: Mobilizations, manipulations, dry needling, MWM, STM
• Mobility exercises to restore OA and AA mobility
  -SNAGS
• Stretching to painful musculature
• Postural strengthening
• Longus colli activation/strengthening
  -chin tuck progressions

Answer 21

CERVICOGENIC HEADACHE: TREATMENT

Question 22

CPG best way to treat cervicogenic headache

Answer 22

1. manip + dry needling
2. exercise + dry needling
3. exercise
4. mobilization + exercise
5. mobilization