cephalgia ( Headache)

General Statistics
Second most common complaint after back pain
“Everyone” has headaches (HA)
More than 80 million ER visits in U.S. per year
Frequency of HA due to rich nerve supply and psychological implications of head pain

General Statistics

Nerves responsible for HA have their source from myelinated C fibers and A-delta fibers in cranial nerves V, IX, X, and roots C1, C2, C3
Pain sensitive structures include the eye, ear, paranasal sinuses, large extra and intra cranial arteries, dural sinuses, periosteum of the skull skin, cranial muscles, and the upper cervical spine
Etiologies
Commonly overlooked etiologies include: food, fever, viral, metabolic, withdrawal, and pharmaceutical
International Headache Society Classifications (see attachment)
History: Questions to ask

Character of pain
Mode of onset
Mode of offset
Time of onset

Relieving factors
Aggravating factors
History: Questions to ask
Precipitating factors
Frequency of attacks
Duration of attacks
Associated symptoms
Family history of headache
Allergies
Seven danger signals of an ominous headache

A “first” headache
Headache due to exertion
Headache with fever
Headache in a drowsy or confused patient
Seven danger signals of an ominous headache

Headache in a patient with nuchal rigidity or meningeal signs
Headache in a patient with abnormal physical signs
Headache in a patient who “looks ill”
Physical Exam
Gait assessment
Vital signs
Fundoscopic exam
Facial symmetry
Head & Neck structures
Deep tendon reflexes
Plantar response
Limb strength
Relevant Muscles
Trapezius
Sternocleidomastoid
Temporalis
Occipitofrontalis
Suboccipital muscles
Masseter
Relevant Muscles
Medial & Lateral Pterygoid
Anterior & Posterior Digastric
Fascial muscles
Splenius Capitis
Posterior Cervical musculature
Deep Anterior Cervical musculature
Cervical Dysfunction
Upper cervical nerves posses fibers for pain from the lower part of the occipital sinus, vertebral and posterior meningeal arteries, and the dural floor of the posterior fossa (C1, C2, C3)
Differential Diagnosis:Migraine Headache
Etiology:
Hereditary component
Not correlated with personality types “A” or neuroses
The worsening or migraine that occurs during periods of intense nervousness, anxiety, and depression is usually due to the superimposition of a tension headache
Vascular spasm followed by vasodilatation
Migraine Headache:Signs & Symptoms
Classic Migraine

Character: throbbing pain
Location: hemicranial
Associated: preceded with visual disturbances and less often with hemi-sensory disturbances, hemiparesis, or aphasia
Migraine Headache:Signs & Symptoms
Classic & Common Migraine
Character: throbbing pain
Location: hemicranial
Associated: photophobia and or phonophobia; tension headache often concomitant
Aggravated: red wine, nuts, aged cheese, chocolate and caffeine containing beverages
Risk factor: women are more affected than men
Migraine Headache:Diagnosis & Treatment
Response to ergot therapy
Drug treatment is widely varied (caffeine, NSAIDS, barbiturates, narcotics, beta blockers, calcium channel blockers, sedatives, and more…)
Prevention by avoiding predisposing factors, decreasing stress, maintaining sleep regularity
Osteopathic treatment would include stabilizing vasculature and associated concomitant tension headache
Differential Diagnosis:Cluster Headache
Etiology
Disturbed hypothalamic biorhythm
Excess smoking and drinking may precipitate via sphenopalatine irritation
Hemicranial (unilateral) cranial dysfunction
Cervical somatic dysfunction with irritation of the spinal accessory nerve
Cluster Headache:Signs & Symptoms
Character: excruciating pain often stabbing
Location: usually near one eye
Associated: tearing, flushed face, nasal congestion, conjunctival congestion (ANS)
Risk factor: males affected more than females
Onset: begins at 20 – 40 years of age
Cluster Headache:Signs & Symptoms
Attacks last 30 – 90 minutes daily for days and then disappear for months (Headache “vacation”)
Alcohol can precipitate but only during an active cycle, not during “vacations”
Some are so painful that they can lead to suicide
Cluster Headache: Prevention & Treatment

Drug treatment is widely varied

Osteopathic treatment would include a thorough cranial assessment
Differential Diagnosis:Organic origin, Subarachnoid hemorrhage

Etiology

Ruptured aneurysm
Arteriovenous malformation
Trauma
Differential Diagnosis:Organic origin, Subarachnoid hemorrhage

Signs & Symptoms

Character: full-blown catastrophic headache
Location: Holocaine
Duration: continuous
Associated: photophobia, retinal hemorrhages, nuchal rigidity, Brudzinski’s sign, Kernig’s sign, obtunded collapse
Differential Diagnosis:Organic origin, Subarachnoid hemorrhage

Diagnosis

CT may show blood and aneurysm
Lumbar puncture may show bloody CSF
MRI
Differential Diagnosis:Organic origin, Meningitis
Etiology

Virus
Bacteria
Fungus
Tuberculous
Differential Diagnosis:Organic origin, Meningitis
Signs & Symptoms
Character: cephalgia is intense, steady, and deep
Location: holocranial pain associated with retro-orbital pain which is aggravated with eye movement
Onset: sub-acute or acute
Associated: fever, generalized convulsions, varied levels of consciousness, nuchal rigidity, Brudzinski and Kernig’s signs
Differential Diagnosis:Organic origin, Meningitis
Diagnosis

Headache with fever and nuchal rigidity
LP reveals pleocytosis, increased protein, and low glucose
CT scan after Tx is underway to R/O brain abscess and subdural empyema
Differential Diagnosis:Organic origin, Increased Intracranial pressure

Etiology

Increased volume
Increased venous pressure
Obstruction to flow/absorption of CSF
Differential Diagnosis:Organic origin, Increased Intracranial pressure

Signs & Symptoms

HA is severe
HA occur with coughing, sneezing, valsalva effort
Associated findings include papilledema, obtunded, focal neurologic signs & symptoms
Differential Diagnosis:Organic origin, Increased Intracranial pressure

Diagnosis

CT
MRI
Avoid LP
Differential Diagnosis:Organic origin, Hypertension
Usually no HA’s until DBP > 120 mm Hg
3 major causes of acute severe hypertension: drugs, pheochromocytoma, neurogenic (paraplegia)
Associated findings include: retinopathy, convulsions, confusion or stupor evolving over several days
Differential Diagnosis:Organic origin, Vasculopathies

Etiology

Temporal (giant cell) arteritis
Dissection of a vessel
Differential Diagnosis:Organic origin, Vasculopathies

Signs & Symptoms of Temporal Arteritis

Character: throbbing and sharp, burning pain
Location: focal headache in the temporal or frontal-occipital region
Onset: gradual and progressive
Aggravated: headache worse at night and with cold
Risk: most common in white females > 50 years old
Associated: weight loss, fever, fatigue, polymyalgia rheumatica, monocular visual loss, jaw claudication
Differential Diagnosis:Organic origin, Vasculopathies

Diagnosis of Temporal arteritis

Increased sed rate
Biopsy

Differential Diagnosis:Organic origin, Vasculopathies

Signs & Symptoms (Dissection of vessel)

Severe, localized HA
History of trauma or vigorous exertion
Diagnosis with CT

Differential Diagnosis:Organic origin, Acute Purulent Sinusitis
Involving the frontal, maxillary, sphenoidal, or ethmoidal sinuses
True “sinus HA” is rare; if present, the patient is usually very ill, with a severe localized HA for hours or days, PND & tender sinuses; often misdiagnosed as tension HA or common migraine but may have these as concomitant HA
Diagnosis: CT
Differential Diagnosis:Tension HeadacheEtiology

Skeletal components

Somatic dysfunctions of the upper cervical unit are going to impinge on the upper cervical nerves which have afferents in the cranium and dura
Differential Diagnosis:Tension HeadacheEtiology

Muscular components

Can be explained by trigger point reflex mechanisms. A myofascial trigger point is a focus of hyperirritability within a taut band of skeletal muscle or the associated fascia that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception
Differential Diagnosis:Tension HeadacheEtiology

Muscular components

Trigger points can result directly from ischemia due to chronically tense muscles, acute overload, overwork fatigue, direct trauma, and chilling.

Trigger points can result indirectly from other trigger points (a.k.a. latent trigger points), visceral disease, arthritic joints, and by emotional distress
Differential Diagnosis:Tension HeadacheEtiology

Soft tissue components

Ligaments can refer pain to sclerotomes which need to be addressed to completely resolve the somatic dysfunction

Lymphatics

Need to free up the thoracic inlet to allow drainage of fluids
Trapezius

The trapezius can have many trigger points but the ones located in the upper fibers are most relevant for cephalgia

Pain referral pattern: Posterolateral aspect of the neck, mastoid process, temple and back of the orbit, and the angle of the jaw
Trapezius
The patient can often be misdiagnosed as having cervical radiculopathy or atypical facial neuralgia. The normally minimal antigravity function of the upper trapezius is overstressed by any position or activity in which the trapezius helps to carry the weight of the arm for a prolonged period

The muscle can also be strained by chronic injury due to overload, carrying a heavy backpack, long telephone calls, and sleeping prone with the head turned to one side
Trapezius

The trapezius can also entrap the greater occipital nerve which enervates the skin of the scalp and the semispinalis capitis muscle
Sternocleidomastoid Sternal division
Pain referral pattern: supra-orbital and deep within the orbit, occipital ridge, and vertex

Associated autonomic findings: excessive lacrimation, reddening of the conjunctiva, apparent “ptosis,” and visual disturbances
Sternocleidomastoid Clavicular division

Pain referral pattern: frontal area which extends across the forehead to the other side, and posterior auricular

Associated proprioceptive findings: spatial disorientation
Sternocleidomastoid
The SCM trigger points can be activated by sleeping on two pillows and keeping the neck in a flexed position, or by keeping the neck in an extended position as in painting a ceiling or sitting in the front row of a theater with a high screen or elevated stage. The SCM is often injured in a “whiplash” injury that might occur in an automobile crash.
Temporalis
Pain referral pattern: widely throughout the temple, along the eyebrow, and behind the eye

Temporalis trigger points may be activated by bruxism, direct trauma such as a fall or an impact to the cranium. The temporalis muscle can also be activated secondary to spasm in the masseter muscle
Occipitofrontalis
Frontal division pain referral pattern: upward and over the forehead on the ipsilateral side

Occipital division pain referral pattern: laterally, diffusely over the back of the head and with pain deep in the orbit