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Headache Tree Laterality of Sx? Bilateral (sx reproduced B at the same time) Unilateral (or U on both sides) Tension HA Tx: Pharmacological Tension HA.

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Presentation on theme: "Headache Tree Laterality of Sx? Bilateral (sx reproduced B at the same time) Unilateral (or U on both sides) Tension HA Tx: Pharmacological Tension HA."— Presentation transcript:

1 Headache Tree Laterality of Sx? Bilateral (sx reproduced B at the same time) Unilateral (or U on both sides) Tension HA Tx: Pharmacological Tension HA Tx: Pharmacological Palpation: Sx may occur ipsilaterally or shift to contralateral side Palpation: sx occur ipsilaterally Migraine HA Tx: Pharmacological Triggers? Neck Motion, Valsalva, Pressure over C1-C3 Alcohol, Occurs at predictable times/day None Cervicogenic HA Tx: PT (jt mobs/manips, stretching, STM, strengthening, postural/NM re-education, TENS, biofeedback) and/or Pharmacological Cluster HA Tx: Pharmacological Hemicrania Continua HA Tx: Pharmacological Hemicrania Continua HA Tx: Pharmacological Red Flags: Worst HA of life, wake up at night, altered/LOC Dizziness No Refer to Vestibular Sheet Refer to MD/ER Adapted from Biondi (2005) Multiple, but not neck motion

2 Differential Dx for Headaches CervicogenicMigraineClusterHemicrania continua Tension Female : Male Ratio F > M M > FF > M LateralityUnilateral (no sideshift) Unilateral with sideshift Unilateral without sideshift Bilateral LocationOccipital to frontoparietal and orbital Frontal, orbital, temporal, hemicranial Orbital, temporalFrontal, temporal, orbital, hemicranial Frontal, occipital, circumferential DurationIntermittent or constant 4-72 hrs15-180’ several times a day Constant with attacks Days to weeks TriggersNeck motion, valsalva, pressure over C1-3 Multiple but neck motion not typical Alcohol, HA occur at predicitable times of day None typicallyMultiple but neck movement not typical Associated Symptoms Absent/similar to migraine, but milder Decreased neck motion Nausea, vommitting, phono/photophobia, visual scotoma Autonomic sx: tearing, rhinorreha, ptosis, miosis, all ipsilateral to pain Autonomic sx may occur Occasional decreased appetite, photo or phonophobia Pharmocological Treatment Anesthetic block, migraine tx, antiepiletic drugs, antidepressant (serotonin and norepinephrine reuptake inhibitors, NSAIDs Typical migraine (ergots, triptans) Oxygen, ergots, triptans Excellent response to indomethacin Simple analgesics, muscle relaxants, mediations used in migraine tx Biondi (2005)

3 Cervicogenic Treatment Tree Limited ROM: Tx: Self stretches, PROM Joint Mobility Assessment: Central/U PAs cervical and thoracic, downglides, OA, AA* Tx: manips (per thoracic CPR or qualified cervical therapist), mobs *Test with Cervical Flexion Rotation Test (Hall 2010) and HEP of self rotation SNAGS (Hall 2007) Soft Tissue Assessment:  Muscle Tension or TrP (UT, levator scap, suboccipitals, SCM, scalenes, paraspinals) Tx: STM, ischemic compression/suboccipital release, stretching, e-stim Postural Assessment: Forward head, rounded shoulders,  or  of thoracic kyphosis or cervical lordosis Tx: postural/NM re-ed, biofeedback, pt education/ -ergonomics Strength/Endurance Assessment: Deep cervical flexors, scapular stabilizers Tx: strengthening/endurance TEs, NM re-ed** ** Test with Craniocervical Flexion Test (Harris et al 2005) and possible tx of low load cervical motor control TEs (Jull 2002) If Any Radicular Like Symptoms: Assess for Radiculopathy CPR, nerve tension tests, and/or TrP (ie: SCM, scalenes) Further Pain Management: - Pt education for fear avoidance - Refer out for pharmacological/injection/behavior tx - Possible surgical intervention

4 Cervicogenic Headache Diagnosis Subjective Location of PainStarts neck, occipital Ipsilateral, vague, nonradicular neck/shoulder/arm Occasional radicular symptoms Forehead, temporal, whole, frontal, orbital Pain CharacteristicsUnilateral without sideshift or Bilateral Moderate-severe Non-throbbing/ dull, aching Non-lancinating Becomes more continuous Varying duration Pain Increases WithNeck movement Posture Awkward head positioning Pressure over ipsilateral cervical/occipital area Objective Cervical ROMDecreased PROM Palpable FindingsTender neck muscles Change in neck muscle properties Pain on C2/3 facet palpation and dermatome Response to BlockadeOccipital nerves, facets, or nerve roots abolish or relieve pain Radiologic Findings (possible)Flexion/extension abnormalities Fracture Congenital anomaly Tumor/rheumatoid arthritis, not spondylosis Neck TraumaPossible OtherNausea, vomiting Edema, flushing Dizziness Phono/photophobia Blurred vision Dysphagia No effect with indomethacin, ergotamine, or sumatripan Hadelman et al (2001)

5 References Antonaci, Fabio, Torbjorn A. Fredriksen, and Ottar Sjaastad. "Cervicogenic Headache: Clinical Presentation, Diagnostic Criteria, and Differential Diagnosis." Current Pain and Headache Reports 5. (2001): Nov Biondi, David M. "Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies." Current Pain and Headache Reports 5. (2001): Nov Biondi, David M. "Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies." Journal of the American Osteopathic Association (2005): S16-S Nov Biondi, David M. "Cervicogenic Headache: Mechanisms, Evaluation, and Treatment Strategies." Journal of the American Osteopathic Association (2000): S7-S Nov Child’s, Cleland, Elliot, Teyhen, Wainner, Whitman, Sopky, Godges, Flynn. “Neck Pain: Clinical Practice Guidelines linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association.” J Orthop Sports Phys Ther 2008; 38(9):A1-A34. Falla, D. "Unraveling the Complexity of Muscle Impairment in Chronic Neck Pain." Manual Therapy 9. (2004): Nov Fernandez-De-Las-Penas, Cesar, Marta Perez-De-Heredia, Alberto Molero-Sanchez, and Juan Carlos Miangolarra-Page. "Performance of the Craniocervical Flexion Test, Forward Head Posture, and Headache Clinical Parameters in Patients with Chronic Tension-Type Headache: A Pilot Study." Journal of Orthopedic and Sports Physical Therapy 37.2 (2007): Nov Fernandez-De-Las-Penas, Cesar, Cristina Alonso-Blanco, Jesus San-Roman, and Juan Carlos Miangolarra-Page. "Methodological Quality of Randomized Controlled Trials of Spinal Manipulation and Mobilization in Tension-Type Headache, Migraine, and Cervicogenic Headache." Journal of Orthopedic and Sports Physical Therapy 36.3 (2006): Nov Haldeman, Scott, and Simon Dagenais. "Cervicogenic Headaches: a critical review." Spine Journal 1. (2001): Nov Haldeman, Scott, and Simon Dagenais. "Choosing a treatment for cervicogenic headache: when? what? how much?.” Spine Journal 10. (2010): Nov Hall, Toby, Kathy Briffa, Diana Hopper, and Kim Robinson. "Long-Term Stability and Minimal Detectable Change of the Cervical Flexion-Rotation Test." Journal of Orthopedic and Sports Physical Therapy 40.4 (2010): Nov Hall, Toby et al. "Efficacy of a C1-C2 Self-sustained Natural Apophyseal GLide (SNAG) in the Management of Cervicogenic Headache." Journal of Orthopedic and Sports Physical Therapy 37.3 (2007): Nov Harris, Kevin D. "Reliability of a Measurement of Neck Flexor Muscle Endurance." Physical Therapy (2005): Nov Jull, Gwendolen et al. "A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache." Spine (2002): Nov McDonnell, Mary Kate, Shirley A Sahmann, and Linda Van Dillen. "A Specific Exercise Program and Modification of Postural Alignment for Treatment of Cervicogenic Headache: A Case Report." Journal of Orthopedic and Sports Physical Therapy 35.1 (2005): Nov 2010.


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