Positive Health Online

Classification of Headaches
There are 5 main classifications of headache:

1. Vascular (migraine/cluster/aneurism);
2. Tension (muscle contracture);
3. Pressure/Inflammatory (brain tumour, infection, cerebrovascular disease,( ICPressure);
4. Cranial neuralgias (trigeminal neuralgia;
5. Dysfunction of TMJt/assoc muscles);
6. Psychotic (usually delusional i.e.; patient "feels worms inside their head" or "bone going rotten").

 
What is the duration?
How long have they had it?

Does coughing and sneezing or changing the position of the head affect the headache?

Yes   sinusitis, brain tumour, post concussion syndrome
Yes   cervical disc prolapse/irr to grt occipital nerve (C2)

With structures above the tentorium cerebelli, pain pathways travel via the trigeminal nerve and are therefore perceived in the frontal, temporal & parietal regions of the head. For structures below the tentorium cerebelli pain pathways travel via the glossopharyngeal / vagus nerves and upper cervical spinal nerve roots and pain is perceived mainly in the occipital region (Ward, 2000).

Examination

• Active / passive movements of the cervical spine/temporomandibular joint;
• Compression test;
• Blood pressure;
• Eye/vision examination.
• Neurological examination including relevant cranial nerve testing;
• Tap over frontal and maxillary sinuses (if you suspect sinusitis);
• Kernig's sign (if you suspect meningitis);
• Vertebro basilar insufficiency.

Red Flags

• Severe pain - subarachnoid haemorrhage, giant cell arteritis, meningitis
• Visual changes - glaucoma, giant cell arteritis (PMR), space occupying lesion
• Associated fever, sore throat and neck stiffness - meningitis
• Associated fever, malaise, anorexia, muscular aches and stiffness, tenderness of scalp - giant cell arteritis
• Alterations of consciousness - chronic subdural heamatoma, subarachnoid haemorrhage
• Neurological symptoms - chronic subdural heamatoma, brain tumour
• NB: If you suspect any of the above then the patient must be referred immediately

Structural Osteopathic Approach to the Treatment of Migraine of Biomechanical Origin

Classification

• Trigger Factors causing a Migraine Headache
• Chemical toxins
• Various E numbers
• Red wine
• Cheese
• Chocolate,
• Bright light.

With the exception of the latter these all have a direct effect on the carotid arteries and ultimately the flow of blood to the brain (Davidoff RA 1995); however, there are also a number of indirect mechanisms, which involve the biomechanics of the cervical spine.

Physiology of Migraine from a Biomechanical Perspective
Irritation to the cervical sympathetic plexus can be caused by a number of factors namely whiplash injury, anterior osteophytes formation, disc prolapse and over sprain to the anterior longitudinal ligament, with associated shortening to longus coli muscle. This combination can result in compression and over stimulation of the cervical sympathetic plexus (Bowles 1993), causing excess sympathetic discharge, resulting in vasoconstriction of the carotid arteries. This is usually noted by the patient as the aura phase (Penderson DM 1991). Excess sympathetic discharge cannot continue indefinitely and eventually it peaks and then abruptly stops. This allows the para sympathetics, to work unopposed causing vasodilatation of the carotid arteries (Moskowitz MA 1984). This reduces the blood, flow to the brain and resultant ischaemia of neural tissue and pain, ensues.

Osteopathic intervention can be to work on the longus coli muscle through soft tissue and MET techniques to reduce pressure on the cervical sympathetic plexus thereby reducing potential irritation, along with correcting dysfunction of the cervical and thoracic spine through manipulation.

Soft tissue Techniques to longus coli

Patient Position
Patient supine head and neck supported to avoid extension.

Procedure 1

1. With the operator standing at the head of the couch.
2. Using finger pads of caudad hand palpate anterior to the articular pillar of the cervical spine and lateral to sterno-cleido-mastoid (SCM)
3. With the operators cephalad hand placed gently on the patient's forehead, start to rotate the head left if allowing the right SCM to relax and visa versa. This gains improved access to left longus coli.
4. Using a gentle cross-fibre type action the left middle fibres of longus coli are drawn towards the midline.
5. Continue to repeat until change in the muscle is felt. Do not over do and observe patients facial expressions at all times. Remember the vital structures in this area.

Cross fibre to longus coli.

Procedure 2 Lower fibres of longus coli

1. 1. Patient remains supine. The operator rotates the head fully to the right to place their thumb under SCM and anterior to the cervical articular pillar.
2. 2. Gentle downward pressure is then placed on the middle fibres of longus coli. This creates a false origin.
3. 3. The operator then introduces side bending left while continuing to place pressure on the right longus coli.This creates a longitudinal stretch to the lower fibres of the muscle.
4. 4. Repeat until a change is felt in the muscle. Again do not over do sidebending.

Longitudinal stretch to the lower fibres of longus coli.

Management Plan

• Once a diagnosis of classical migraine is made the follow should be considered
• Examination of cervical/thoracic spines identification of joint restriction dealt with by articulation, MET or HVT according to the tissue state.
• Palpation of soft tissue i.e. longus coli sub occipital regions assessed for hypertonia and dealt with through soft tissue / MET techniques accordingly.
• Adaptation of patient activities/ergonomics/diet through advice to prevent repetitive migraine episodes, thereby improving patient's day-to-day activities.

References
Bowles DB. Visual field effects of classical migraine Brain & Cognition 21:181-183. 1993.
Davidoff RA. Trigger factors and non pharmacological approaches Migraine, Manifestations and Management. 183-189. 1995.
Kidd RF. Musculoskeletal dysfunction of the neck in migraine and tension headache Headache, 33(10): 566-569. 1993.
Pederson DM. Migraine aura without headache Journal of Family Practice 32:5-7. 1991.
Greenman PE. Principles of manual medicine. 2nd Edition. Lippincott Williams and Wilkins. Baltimore, USA. 1996.
Stone C. Science in the art of osteopathy. 1st edition. Nelson Thornes Ltd, UK. 1999.
Thomas J., Monaghan T. Clinical examination and practical skills. 1st Edition Oxford University Press, UK. 2007.
Ward RC. et al. Foundations for Osteopathic Medicine. 2nd edition. Lippincott Williams and Wilkins, Baltimore, USA. 2002.