Headaches – a top ten reason for seeking outpatient care
This description of headaches was made famous by Robert Ulrich’s Excedrin commercials almost twenty years ago, and echoes the continued all-encompassing pain suffered by many today.
Patients with headaches account for 9 million visits to primary care physicians annually, and among all outpatient visits, headache is listed as the number seven reason for seeking care. Over 45 million Americans suffer from some form of headache. Peak incidence of this condition strikes people in the most active and productive periods of their lives ages 25-55. Functionally, headaches have a devastating effect on quality of life. According to the RAND short form Quality of Life instrument, Migraine sufferers experience a quality of life inferior to other chronic conditions including arthritis, diabetes, back pain and depression.
We’re not talking simple Brain Freeze
Baskin Robbins has its 33 flavors of brain freeze and headaches alike come in a whopping 27 different varieties. To simplify these types are broken into three main types: (1) vascular (migraine), (2) tension-type and (3) traction and inflammatory. True vascular and inflammatory headaches are usually managed with medication and strategies to identify/modify triggers. A common subtype of the tension headache, cervicogenic headache often has a musculoskeletal component. The World Cervicogenic Headache Society defines this type as “referred pain perceived in any part of the head caused by a primary nociceptive source in the musculoskeletal tissues innervated by cervical nerves”. Symptom with this type of headache commonly begin in the neck and radiate into the head. Pain can be dull, a deep ache or severe and intense. Headaches may be present upon waking or begin or worsen throughout the day, especially with sustained neck postures. History of neck trauma may or may not be involved.
Sources of Pain/dysfunction
Cervical (neck) facet joints have been recognized as a source of cervicogenic headache. Specifically the upper three cervical segments are capable or referring pain into the neck, base
of the skull and temples. Manual therapy examination of mobility in the neck has been used to identify alterations in joint movement and reproduce head and neck pain. A study of this examination by Jull found it to be as accurate as a radiologically controlled diagnostic blocks in detecting symptomatic joints in the cervical spine. While muscle tightness has not been shown to be a strong feature of these headaches, decreased muscle strength and endurance are commonly associated with CGH.
Diagnostic Criteria
The following Criteria was established by the International Headaches Society for the diagnosis of cervicogenic headache. All categories (A-D) must be met to make a diagnosis.
A. Pain is localized to the neck and occipital region and may project to forehead, orbital region, temples, vertex, and ears.
B. Pain is precipitated or aggravated by special neck movements or sustained neck posture.
C. At least one of the following:
a. Resistance to or limitation of passive neck movements
b. Changes in neck muscle contour, texture, tone, or response to active and passive stretching and contraction.
c. Abnormal tenderness of neck muscles
D. Radiological exam reveals at least one of
The following
a. Movement abnormalities in flexion/extension
b. Abnormal posture
c. Fractures, congenital abnormalities, bone tumors, RA, other distinct pathology except spondylosis and osteochondrosis
Effective Treatment
Manual physical therapy of the cervical spine has been shown to be effective in relieving or reducing the occurrence of CGH. Following treatment, improvements were noted in headache frequency, duration, and intensity. Reduced need for pain medication has also been reported in the literature.
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