Pre-Learning Benign Headache PDF

Chandra Ricks  Practice and Problem Solving Communication Patient Awareness Team Working Professional Knowledge/Skills...

Chandra Ricks  Practice and Problem Solving Communication Patient Awareness Team Working Professional Knowledge/Skills Year 3 CLINICAL NEUROLOGY 2  Understand the hallmark principles of benign, stable headaches  Recognise common pathologies causing stable HA  Understand key questions to enable differential diagnosis of headaches  Understand chiropractic role in headache treatment 3  Many start when person in teens/early 20s  Second peak: 40s - due to structural changes in body  Repetitive with pain free periods  Stable features ◦ Location ◦ Pain quality ◦ Pain intensity ◦ Triggers ◦ Duration and frequency ◦ Associated symptoms  V  I – chronic sinusitis  N – tension headache  D – cervicogenic HA: osteoarthritis, myofascial referral  I – rebound headache  C  A - migraine w/ aura, migraine w/out aura  T – cervicogenic HA: facet syndrome  E –menstruation, menopause, diabetes, hypoglycaemia…  S – dehydration, TMJ, eye strain, anxiety/depression  Vascular Infection Metabolic Traumatic/ toxic Referred ICP Psychogenic  A benign, recurrent  Strong genetic neurovascular component headache leading to  Typically starts in severe pain teens, early 20s Commonest severe  Can start in older episodic recurrent population, but must headache cause be referred out to 20 sub-classifications exclude “big bads” as (ICHD-2) atypical to start later What is it? Who gets it?  Pathophysiology- neurovascular ◦ Channelopathy – calcium channels over-excited ◦ Vasospasm – by product leading to pulsatile pain ◦ Aura – is cortical dysfunction – indicates where starts  Phases to occurrence ◦ Premonitory – 12-24 hours prior – vague symptoms alert is coming  Fatigue, neck/stiffness pain, hyper/hypoactivity, depression… ◦ Aura – 99% visual symptoms ◦ Headache period ◦ Resolution ◦ Recovery (post dromal)  Indicates a localisable point where channelopathy is initiating  Creates specific neurological findings ◦ Visual changes – flashing lights, halo… - most common ◦ Sensory loss – arm or facial numbness ◦ Weakness/paralysis – usually affecting part of body ◦ Speech deficits  Symptoms always the same per person and last no more than 1 hour before resolving  Unilateral around an  Aura precedes eye headache – typically 5  Pulsatile quality minutes  Severe pain – ADL ◦ Most common is visual inhibited disturbances ◦ Must lie in dark room  Headache follows –  Nausea/vomiting same symptoms as migraine w/out aura  Photophobia  Phonophobia  4-72 hours Migraine w/out aura Migraine w/aura  Treatment – 2 categories ◦ Abortive (to resolve)  NSAIDs, Triptans, dopamine antagonists ◦ Preventative  Avoid triggers (lack of sleep, food, stress)…  Small studies - chiropractic effective for prevention of migraine  Amiveg – calcitonin gene-related peptide blocker (to stop calicum overactivity)  Preventative treatment – 50% reduction in frequency or duration considered good outcome  Is a recurrent  Most common type of headache carried by benign headache the trigeminal nerve ◦ Most people will leading to sensation of experience at some point pressure around the head  May be triggered by stress, muscle  Categorised by tension, poor posture frequency  Exact cause still ◦ Infrequent to chronic ◦ Chronic can be disabling unknown What is it? Who gets it?  Symptoms ◦ Duration 30 mins-7 days ◦ Usually bilateral, vicelike / band around head  Mild to moderate level of pain ◦ Not aggravated by routine physical activity  Can work through a headache ◦ No nausea/vomiting ◦ May be photo or phonophobia, not both ◦ May be tenderness of cranial and neck muscles  Headache originating  40+ years from a structure in the ◦ Structural change begins neck: to show ◦ Facet joint (often C2/3) ◦ Arthrokinetic reflex =  Restriction or OA myofascial pain ◦ Myofascial pain  Younger people – ◦ Muscle spasm myofascial pain ◦ Ligament – tend to be ◦ Postural challenge WAD mech. ◦ Hypermobility ◦ Capsule – WAD mech. ◦ Disc What is it? Who gets it?  Moderate/severe unilateral neck and occiput pain  Biomechanical pain ◦ Sharp on movement of neck (compression of facet or trigger point, passive stretch of muscle) ◦ Dull, achy at rest ◦ Stiffness present as well  Pain aggravated by movement of neck or sustained position  Restricted A/PRoM  Depending on structure affected may have other symptoms: dizziness, arm pain…  Clinical characteristics of cervicogenic headache. (Modified from Biondi DM: Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2000;100(9 Suppl):S7-14.)  Signs: ◦ Observe – neck shortening, anterior head carriage, head tilt, hypermobile positioning…. ◦ Difficulty with palpation (“dirty”) in OA ◦ Reductions in RoM  For patient – hypermobile will still be WNL ◦ Joint restrictions on motion palpation ◦ Local pain on compression/maximal forminal compression ◦ Valsalva manoeuvre – increase local pain ◦ Hypertonicity of paraspinals/sub-occipitals  AKA Trigger point referral ◦ Subtype of cervicogenic headache ◦ Active TgPts prevalent in migraine sufferers ◦ Active TgPts prevalent in tension type headache  Occurs simultaneous to neck/shoulder pain  Trigger points can refer around the temples, eye or frontal region  Often described as a constant pressure type pain  May lead to low grade nausea  Lack of fluid in the body → brain to temporarily contract  Brain tissue pulls away from skull – tensions dura mater → headache  Symptoms: ◦ Can be a mild dull ache  No facial pain or pressure – DDx sinusitis ◦ Can feel like an intense migraine (pulsatile pain)  More variable distribution: front, back, side, or all over the head  Other symptoms of dehydration may be present: ◦ Extreme thirst ◦ Reduced or dark coloured urination ◦ confusion ◦ Dizziness (from reduced blood pressure) or fatigue ◦ dry, sticky mouth ◦ loss of skin elasticity (skin pinch test on hand) ◦ Increased heart rate  People at higher risk of dehydration include: ◦ Infants and children ◦ Elderly people ◦ people with chronic illnesses (e.g. diabetes and kidney disease) ◦ Patients on diuretics (furosemide – increase urine output) ◦ Endurance athletes ◦ People who live in higher altitudes or hot climate  Symptoms should relieve when fluid levels appropriate ◦ May not be immediate – can take time  May need to consider electrolyte replacement if lost during extreme activity (sweating), heat or via diuretic use  Prevention ◦ 4-6 cups water daily – spread out and slowly intake  If gulp huge water, hits bladder and pee it out! ◦ Fluid rich foods  Viral infection common  May have resulted ◦ Self-limiting for up to 3 from a previous weeks bacterial infection  Headache around the  Bacterial resistance to eyes/forehead antibiotics  Nasal congestion and  Low grade drip inflammation  Discoloured mucous  May not have acute  May be bacterial – watch signs of for referral into the congestion/mucous jaw/teeth Acute sinusitis Chronic sinusitis  Symptoms ◦ Sharp, boring pain ◦ Often worse in the morning ◦ Slight swelling around the eyes  Signs ◦ Percussion of sinus is painful ◦ Forward flexion of neck is painful  Diagnosis – clinical typically  Disorder of the TMJ Caused by leading to pain in the Misaligned jaw due to jaw and potentially dental misalignment referring to the side of TMJ arthritis the face Injury or trauma to Second most common bones in the joint or jaw cause of chronic pain Overuse injury to ◦ Often misdiagnosed as muscles or pressure tension or migraine HA from teeth grinding Trigger points in mastication muscles What is it? Who gets it?  Symptoms include: Tight, dull/achy headache around the temples, ear and jaw Often unilateral Aggravated by jaw movement (e.g. chewing) and relieved with rest Clicking, popping or grinding noises on jaw movement possible Difficulty opening mouth fully Normal is 3-finger test Jaw locking when open your mouth  Physiological  Seen in people with dependency on chronic HA types analgesic medication  Often migraine or leads to headache tension pain when medication  Cervicogenic from OA wears off  Stronger types of pain  Can also occur with medication lead to as caffeine use well  Cause dependent What is it? Who gets it?  Bifrontal headaches  Non-specific pain quality  Will only respond by taking more of the habitual analgesic  Occur typically on awakening ◦ b/c lack of meds through night allow an adequate period for withdrawal symptoms to appear  Treatment ◦ Removal of the offending medication and education ◦ May take days to weeks to fully resolve – medication dependent ◦ Stronger meds requires medical supervision  Hormonal changes will often trigger headache  May be described as dull or throbbing  Will be repetitive and episodic  Often seen in people from: ◦ Hypoglycaemia ◦ Diabetes (hyperglycaemia) ◦ Menstruation ◦ Menopause ◦ Other  Look for repetitive trigger – menstruation or lack of eating  Look for other symptoms: ◦ Menopause – 40-58 (typical 51)  Mood changes, hot/cold flashes, menstrual irregularity, brain fog, skin changes, insomnia… ◦ Diabetes type 1 - young person  sugar craving, thirst, increased urination, weight loss ◦ Diabetes type 2 – older person  Over-weight, feeling a little run down or lethargic, slightly unwell, may have peripheral neuropathy present, may have skin lesions present  Headaches will  Reassure but refer: superimpose ◦ New headache in ◦ 2 together not paediatric uncommon ◦ New headache in ◦ DOC each separately 50+ until proven linked ◦ Stable headache  Many don’t have becoming more exam findings frequent ◦ Detailed history  EG tension or using principles of cervicogenic stable HA  Evidence shows that chiropractic care can be useful in treating: ◦ Migraine – likely due to trigger prevention ◦ Cervicogenic headache ◦ Tension headache  Limitations ◦ Small studies ◦ Evidence sometimes weaker due to this  Pain sensation from front of head, face and anterior skull contents from CN5  Eyes – can be referred from carotids, CN5…  Dental – can be referred…  Generally parenchyma has no nociceptors  Mechanisms of pain for pain creating structures ◦ Meninges or capsule ◦ Distension of a vessel ◦ Inflammation  Red flags ◦ “new” headaches – generally people have patterns “new” headaches – generally people have ◦ Particularly patterns if single episodes, onset of seconds- weeks Particularly if single episodes, onset of ◦ Progressive or “worst ever” seconds-weeks ◦ Constant Progressive or “worst ever” ◦ Worse Constant lying down – may indicate raised ICP Worse ◦ Other lying downsigns neurological – may indicate raised ICP Other  EG neurological vertigo, signs diplopia, nystagmus, dysarthria, EG vertigo, diplopia, nystagmus, dysphagia… dysarthria, dysphagia…  General inspection/vitals ◦ rash, BP, pulse, temperature,  Consciousness – mental status  Cranial nerves – could do full screen  CN2, 3/4/6 most sensitive  Ophthalmoscope (papilledema)  CN 9/10, CN12  Other neuro  EG cerebellum, soft touch/pin prick  Cervical screen ◦ Special tests – Kernig, Brudzinski…  Inconclusive (favourable) evidence for manual therapy (osteopathic care, spinal mobilisation) in treating tension-type headache (not evaluated in the UK evidence report). Inconclusive (unclear) evidence for spinal manipulation in treating tension-type headache (no change from the UK evidence report)  Moderate (positive) evidence for manipulation and mobilisation for miscellaneous headache (change from inconclusive (favourable) evidence in the UK evidence report) Chiropr Man Therap. 2014 Mar 28;22(1):12 Clinical effectiveness of manual therapy for the management of musculoskeletal and non- musculoskeletal conditions: systematic review and update of UK evidence report. Clar et al.  Moderate (positive) evidence for mobilisation techniques in cervicogenic headache.  Inconclusive (non-favourable) evidence for friction massage and trigger points in cervicogenic headache  Pain resolves within 3 months after successful treatment of the causative disorder or lesion  1. Migraine 1. Head/neck trauma 2. Cranial or cervical vascular 2. Tension-type headache disorder 3. Trigeminal autonomic 3. Non-vascular intracranial cephalalgias disorder  Group of headaches – 4. Substance/withdrawal  commonest cluster 5. Infection headache 6. Disorder of homeostasis 7. Structures of head/face 4. Other primary 8. Psychiatric disorder headaches 9. Cranial neuralgias & CNS facial pain 10. Other HA, cranial neuralgia or facial pain Primary Headache Secondary Headache  Repetitive attacks of severe, unilateral headache occurring in clusters across a time period  VERY severe, unilateral eye pain ◦ Suicide headache – patient “not know what to do with themselves”  At least 1 of ◦ ipsilateral eye redness and/or lacrimation and/or eyelid swelling ◦ ipsilateral nasal congestion and/or rhinorrhoea ◦ ipsilateral forehead and facial sweating ◦ ipsilateral miosis and/or ptosis  Onset age 20-40, M≥F  Cluster period lasts weeks-months ◦ Each attack is 15-180 minutes ◦ May reoccur at same time each year  Remission periods months-years (rare chronic CH) RX Greater occipital nerve stimulation may be effective Responds to oxygen – unknown mechanism  Migraine and other primary headaches, McGregor & Jensen. Oxford pain management library  International Headache Society ICHD-II  Migraine and other Primary Headaches, McGregor & Jensen, Oxford Pain Management Library  Bogduk N. The anatomy and pathophysiology of neck pain.Phys Med Rehabil Clin N Am 14(2003) 455-472  Petty NJ, Moore AP. Neuromusculoskeletal Examination and Assessment (2001). Churchill Livingstone – Headache SNAG test