Got Headaches?

headachesNone of us enjoy having a headache. But yet, many people suffer from them daily. In the general population, headaches have a reported prevalence of 16%, where 5% of adults experience them on a daily basis (Castillo et al, 1999). Many more headaches go unreported. They often can be debilitating, make us stay home from work, and make us irritable.

There are many varieties and causes of headaches. One type, cervicogenic headache, is characterized as referred pain from the cervical spine. It is characterized by neck pain and dysfunction of neck mechanics. The neck is the source of the pathology and then symptoms are referred to regions of the face and head. There are clinical signs that are positive such as mechanical dysfunction of the neck facet joints (IHS, 2012). There are multiple early sources that agree that headaches have origins from the level of neck vertebrae of C3 or above (Bogduk et al., 1985; Edeling 1988; Jull, 1988; Price et al., 1983). According to Bogduk (1992), these anatomical structures can include muscles, facet (zygopophysial) joints, capsules, ligaments of the upper three cervical segments (C1, C2, or C3), nerves, dura mater, spinal cord, or the vertebral arteries.

Another chronic headache is the tension-type headache. These are episodic or chronic (IHS, 2012) and result in an increased tenderness to the tissues (muscles, tendons, fascia) around the cranium, where muscles were found to be more sensitive than tendons (Nie et al., 2005; Fernandez-de-las-Penas et al., 2008, 2009). There is a prevalence of 40-80% over a one-year time frame.

Migraines are more severe and sometimes more disabling. An estimated 10-12% of adults had a migraine in a year’s time; women tend to be more prone to migraine headaches than men. The International Headache Society defines migraines as having certain qualities: unilateral (affecting only one side) location, pulsating quality, moderate or severe intensity, and aggravation by routine physical activity. There are experiences of nausea and/or vomiting with or without photophobia (sensitivity to light). An aura may also be present. Auras consist of visual disturbances, unilateral parethesias (tingling or pricking sensations), unilateral numbness, unilateral weakness, aphasia (loss of ability to understand or express speech) or unclassified speech difficulty (IHS, 2012).

Although migraines, cervicogenic headaches, and tension-type headaches are separate conditions, there is support that they have some similar underlying mechanisms, including cervical spine dysfunction (Nelson, 1994; Featherstone 1985). Some authors suggest there is a continuum between them because the aggravating factors and precipitating factors are the same or similar (Nelson, 1994; Rasmussen et al, 1992).

There are many causes for headaches. Some of the causes that need to be assessed include hydration or nutritional deficits, infection, vascular disorder, intracranial disorder, substances or withdrawals of them, structures on the head (eyes, ears, sinus, teeth, or mouth), psychiatric disorder, degenerative changes of the neck joints. The location of the headache can also tell us what potential causes have provoked it. To complicate things, an individual may have more than one cause of a headache at one time, because different forms of headaches can coexist. Thorough questioning and assessment is required to ascertain the suitable cause of the headache and then appropriate treatment can ensue.

One of the easiest headaches to treat is the cervicogenic headache. Because its cause is rooted in the neck, the neck’s assessment is imperative to obtain which joints are provocative. The mechanism of pain referral is usually the first three cervical vertebrae’s joints. Almost always there are deficiencies in muscles to the deep postural controlling muscles of the neck and shoulder girdle. Poor posture, including prolonged neck flexion, contribute to the pathology.

Physical therapy treatment for the cervicogenic headache is multifaceted. Education on proper work stations, ergonomics, and posture are a simple start. To have an immediate decrease in tension, therapeutic massage for the neck and shoulder muscles as well as working out any trigger points, need attention. Because the joints often have a significant element to the cause of these headaches, joint work is obligatory. After addressing the anatomy of the neck manually, it is then necessary to retrain the muscles to control the biomechanics of the neck appropriately. Often there is an imbalance of postural muscles that need to be addressed. As well as the deep anterior neck muscles, the muscles that control the shoulder to be posturally optimal (down and back) habitually have deficits. This therapeutic exercise will allow the muscles to have improved tissue tolerance for a patient’s daily activities, thus prolonging the onset, or eliminating a headache all together.

If you suffer from headaches, contact the MTI Physical Therapy clinic in your neighborhood to schedule an appointment with one of our highly skilled and trained Physical Therapist and begin your path to recovery.

Rett Nicolai, PT, DPT, FAAOMPT
Physical Therapist
MTI Physical Therapy – First Hill

References:

Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther 15 (1): 67-70, 1992.
Bogduk N, Corrigan B, Kelly P, Schneider G, Farr R. Cervical headache. Med J Aust 143: 202, 206-7, 1985.
Castillo J, Munoz P, Guitera V, Pascual J. Epidemeiology of chronic daily headache in the general population. Headache 39: 190-
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Edling J: Manual therapy for chronic headache. Norwich, Norfolk, England: Butterworth-Heinemann, 1988.
Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 25: 194-98, 1985.
Fernandez-de-las-Penas C, Cuadrado M, Gerwin R. Referred pain elicited by manual exploration of the lateral rectus muscle in
chronic tension-type headache. Pain Medicine 10 (1): 43-8, 2009.
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International Headache Society. Cervicogenic, tension type headache, and migraine headache definition. Available at
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Nelson CF. The tension headache, migraine headache continuum: a hypothesis. J Manipulative Physiol Ther 17: 156-67, 1994.
Nie H, Kawczynski A, Madeleine P, Arendt-Nielsen L. Delayed onset muscle soreness in neck/shoulder muscles. Eur J Pain 9:
653-60, 2005.
Price D, McGrath P, Rafii A, Buckingham B. The validation of visual analog scales as ratio scale measures for chronic and
experiemental pain. Pain 17: 45-56, 1983.
Rasmussen B, Jensen R, Schroll M, Olsen J. Interactions between migraine and tension type headaches in the general
population. Arch Neurol 49: 914-918, 1992.

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