According to leading UK consultant neurologist John Patten, headaches are the most common symptom come across in medicine. The NHS report that the highest incidence of headaches are tension-type and neck related. National Institute for Health and Clinical Excellence (NICE) state that over-medicating is a factor linked to the increasing incidence of chronic headaches.
There are many types and causes of headaches, many types with overlapping symptoms. As a manual therapist the history taking is therefore the most important part of the treatment, which is highlighted by Patten who emphasises that the patients history is our best diagnostic tool.
Types of headaches
- Vascular: migraine and cluster headaches
- Tension: muscular contraction
- Cervicogenic: referred from neck structures
- Pressure: inflammatory: tumour, infection
- Cranial neuralgia: facial pain: trigeminal neuralgia, temporal mandibular joint/muscular pain (TMJ)
- Psychotic pain: delusional explanation of pain ie “feels like worms crawling”.
- Eye strain and sinus problems can also cause headaches along with dehydration.
What headache have I got?
Diagnosis is the difficult part and I guess the main reason for not responding to treatment or medication. Cervicogenic headache pain is usually one sided referred from muscles or joints of the neck but neck pain and shoulder tension is also a common symptom of migraine sufferers. It is however thought that tension -type and cervicogenic headache suffers have more myo-fascial involvement than migraine sufferers. Headaches due to eye-strain is also a common diagnosis but if the headache occurs in the morning it is unlikely to be due to eye-strain, more likely if the headache is during or after a days work.
What an Osteopath will do?
An osteopath will ask many questions, some of which you may think irrelevant but this is necessary for both your safety as a patient and for the osteopath to decide whether it is treatable osteopathically or if further examinations are required by your GP or a specialist. You are likely to be asked, when it started, location of pain, if there is a daily pattern, what kind of pain and how severe, duration of the headache, is it seconds, hours, days, is there a trigger or does a particular movement aggravate it, do you have visual changes or any fever, sore throat or a stiff neck.
Some tests and an examination will follow the questioning, active and passive movements of the neck and spine, possibly blood pressure and a neurological examination if felt necessary. Treatment will begin once the osteopath is happy that your headache has a musculo-skeletal component and no red flags. Red flags are more worrying symptoms that may accompany the headache that would require referral to a GP, specialist or although uncommon to A&E, such as severe pain/worst ever headache or a rash and neck stiffness.
Musculo-Skeletal structures that may contribute to headaches
Temporomandibular joint (TMJ) of the jaw controls chewing and movement of the jaw with the aid of the surrounding muscles. Headaches associated with the TMJ are neuropathic involving the trigeminal nerve which has 3 branches, as shown in the image. It is thought that the nerve becomes hypersensitive due to compression of the arteries that supply the nerve, known as vascular compression. This can be caused following dental work and is common in patients suffering from MS due to de-myelination of the nerve. The pain is usualy quite severe and shooting lasting only seconds but can be on going.
TMJ pain may also be via the muscles that connect the jaw to the scull, those used for chewing. If the balance between the teeth, muscles and joint are somehow altered this can lead to inflammation and or degenerative changes of the joint and face or head pain, so it is important that the teeth meet correctly.
Sub Occipital muscles
Trigger points may occur in these muscles (see image above) which may refer pain to the back of the neck, side of the head, the eye and forehead. severe headaches can refer to the posterior eye from these trigger points according to the American college of Manual Medicine. These trigger points are thought to be brought on by stress, compromised posture ie cradling the phone or long hours at a PC, even the road bike cycling position causing hyper- extension of the neck can tighten these muscles and lead to headaches. Trigger points can also be aggravated by emotional stress, trauma or even nutritional inadequacy. Some sources including osteopath Philip Greenan believe that the vertebral arteries that pass close to the sub occipital muscles may become impinged by these hypertonic muscles and lead to reduced blood supply to the cranial structures and cause headaches, Travell & Simon’s however rebuke this.
Cervicogenic headaches according to Osteopath David Biondi, are chronic and one sided referred to the head from bony or soft tissue structures of the neck. Trigger points are hyper-irritable regions of contracted muscle which have a reduced pain threshold and refer pain in predictable patterns. Trigger points in the upper shoulders, between the shoulder blades and sub occipital muscles refer pain to the head up on finger pressure.
Trials have show that a combination of manual therapy, such as osteopathy alongside an exercise programme led to long-term control of these tension-type headaches. In 2004 it was shown by Bronfort that manual manipulation treatment was as effective, short term for chronic headaches, as prescribed drugs such as amitriptyline, but with much fewer side effects .
Osteopaths may use many techniques to help ease headaches, from manipulation of the neck and upper spine joints to gentle soft tissue massage , lymphatic drainage techniques, dry needling /trigger point therapy and acupuncture. some stretching exercises may be given with advice on posture correction and possibly discuss an exercise regime.
If you suffer with headaches and want to know if an osteopath can help please contact me at www.osteopath-west.co.uk or leave a comment at the end of this blog. For appointments call Lisa on 07956 954093