Physical Therapy’s role in headache treatment

Amy Nichols, DPTMidAmerica Neuroscience Institute

• MidAmerica Neuroscience Institute– Consultants in Neurology– MidAmerica Neuroscience Foundation

About me

Physical Therapy Presentation to Headache

Support Group

• 2 out of 3 children will experience a headache by the age of 15

• 9 out of 10 adults will experience a headache in their lifetime

• It is the most common form of pain and the most common reason for missing work

• Estimated about 45 million American’s suffer from chronic headaches

• About 70% of sufferers are women

Headache Occurrence

NIH.gov

• Published by the International Headache Society

• Classifies more than 150 types of primary and secondary headache disorders

International Classification of Headache Disorders

• Primary headaches- occur independently, rather than as a side affect of another medical condition. (Migraine, tension, cluster, and miscellaneous)

• Secondary headaches- symptoms of another medical condition. (head/neck trauma, cranial/cervical vascular disorder, non-vascular intracranial disorder, substance or substance withdrawal, infection, disorder of homoeostasis, disorder of cranium/neck/eyes/ears/nose/sinus/ teeth/mouth/other facial/cranial structure, psychiatric disorder )

Primary vs. Secondary

• Subjective– Headache diary?– Frequency, intensity, duration, location?– Limitations at work and home?– What are their symptoms? – Is there more than one type?– Recent onset or past medical history of headaches?– Recent change in headaches?– Does anything relieve or aggravate symptoms?– Has the patient recently started a new medication?– Is there neck pain/shoulder pain? And does it occur

with or without the headaches?– Sleep position?

Physical Therapy Evaluation

• Headache journal – Time of day– Duration – Intensity– Symptoms– Activity prior to episode– Medications prior or after episode– Amount of sleep the previous night– Emotional condition– Weather or daily activity– Foods consumed in the past 24 hours– Menstrual cycle

Subjective Evaluation

• Posture Assessment (Gown for females, generally shirtless for males)

• Posterior View– Scapular position– Cervical position– Weight bearing/trunk lean

Objective Evaluation

Video From Live Presentation

• Side view– Plum line alignment– Presence of humeral

internal rotation– Trunk position– CT junction– OA position

Objective Evaluation

• AROM/PROM: scapular upward rotation, shoulder flexion/ER/IR, cervical rotation, flexion, extension, forward head posture

• Strength• Reflexes• Sensation• Manual Assessment of spinal movement• Soft tissue assessment of muscle tightness

Objective Evaluation

• Presence of trigger points: hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands or muscle fibers•Active trigger points- actively refers

pain locally or to a referred area.•Dormant/Latent trigger points- does

not yet refer pain, but may do so when pressure or strain is applied.

Myofascial trigger points

Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia 2006; 26:1061-1070.

•Caused by acute or chronic muscle overload, activation, disease, psychological distress, homeostatic imbalances, direct microtrauma or macrotrauma.

Myofascial trigger points

Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia 2006; 26:1061-1070.

Myofascial Trigger PointsType of Headache Probability of

myofascial trigger point

Migraine High

Tension-type Headache Very high

Cluster Low to moderate

Miscellaneous vascular Low

Associated with nonvascular intracranial disorder

Low

Associated with substances or their withdrawal

Low to high

Associated with noncephalic infection

Low

Associated with metabolic disorder

Low

Cervicogenic headache HighSimons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins 1999.

Upper Trapezius

Trigger Points

Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins 1999.

Sternocleidomastoid

Suboccipitals

Trigger Points

Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins 1999.

Splenius Capitis

• Educate Patient on condition– MRI’s, objective measurements found, reference to

spinal/scapular model, Netter’s Anatomy, Travell and Simmons– Send relevant information home for the patient (posture

correction, computer sitting posture, etc.)

Initial Evaluation

Headache triggers

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Cervicogenic

Blood pressure

Myofascial Trigger Points

• Manual Therapy• Therapeutic Exercise

– Cervical strengthening– Scapular strengthening– Stretching

• Neuromuscular Re Education/ Therapeutic Activities– Posture correction– ADL correction– Taping

Follow Up visits

• Imagine Plum line intersecting ear, shoulders and hips

• Maintain Lumbar, Thoracic and Cervical natural cures

• Keep the top of the monitor at the top of the head, to maintain about 20-30 degrees of eyesight below the horizontal

• Keep a comfortable viewing distance about 22inches away

• Look away from the monitor at least once every 30 minutes

• Keep documents at a close viewing level

Proper Desk Posture

• American Headache Society- group of health care providers dedicated to the study and treatment of head and face pain. Publish the medical journal Headache. Sponsor the AHS Committee for Headache Education (ACHE)

• http://www.americanheadachesociety.org

• http://www.achenet.org/

- (MIDAS) Migraine Disability Assessment Test, Trigger handouts, headache log information

Resources

• International Headache Society- world resource information, publish Cephalalgia. Has a member and non-member portion of the website. Learning center, IHS guidelines

Resources

http://www.i-h-s.org/

• The National Headache Foundation- goal is to enhance the healthcare of headache sufferers

Resources

http://www.headaches.org/

• “Headache U”- Chart your course to relief

• Educational modules

• Physician finder

• Patient oriented

• The National Institute of Health’s National Institute of Neurological Disorders and Stroke– Mission is to reduce the burden of

neurological diseases

Resources

• Information for clinicians and patients

• A to Z disorder summaries

• Clinical Trial information for researchers and patients

http://www.ninds.nih.gov/index.htm

• Borsa PA, Timmons MK, Sauers EL. Scapular-Positioning Patterns During Humeral Elevation in Unimpaired Shoulders. J Athl Train. 2003 Jan-Mar, 38(1): 12-17.

• Yinen J., Takala E., Nykanen M, et al. Active Neck Muscle Training in the Treatment of Chronic Neck Pain in Women: A Randomized Controlled Trial. JAMA. 2003; 289(19):2509-2516.

• National Institute of Health, National Institute of Neurological Conditions and Stroke headache information page. http://www.ninds.nih.gov/disorders/headache/headache.htm

• Schwedt, T., R.E. Shapiro, Funding of research on headache disorders by the National Institutes of Health. Headache. 49:162-169 (2009).

• Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. Cephalalgia. 2004; 24(suppl 1):1:160. http://ihs-classification.org.en

• Hoving J, et al. Manual therapy, Physical Therapy or Continued Care by a General Practitioner for Patients with Neck Pain. Ann Intern Med. 2002; 136:713-722.

• Quinn C, Chandler C, Moraska A. Massage Therapy and Frequency of Chronic Headaches. American Journal of Public Health Oct. 2002, Vol 92, No. 10.

References

• Cools AM, et al. Rehabiliation of Scapular Muscle Balance: Which Exercises to Prescribe? American Journal of Sports Medicine 2007 35: 1744.

• Roth JK, Roth Rs, Weintraub JR, Simons DG. Cervicogenic headache caused by myofascial trigger points in the sternocleidomastoid: a case report. Cephalalgia, 2007, 27, 375-380

• Biondi D. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. JAOA. 2000; 100:9.

• Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia 2006; 26:1061-1070.

• Silberstein SD, Lipton RB, Dalessio DJ. Overview, diagnosis, and classification. In: Silberstein SD,Lipton RB, Dalessio DJ, eds. Wolff’s Headache And Other Head Pain. 7th ed. Oxford, England:Oxford University Press; 2001:20.

• Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins 1999.

• Bendtsen L, Jensen R, Jensen NK, Olesen J. Muscle palpation with controlled finger pressure: new equipment for the study of tender myofascial tissues. Pain, 1994, 59:235-239.

References