1. Study Group Laura Maidment

2.  Primary headaches 1) Migraine 2) Tension –type headaches 3) Cluster headaches 4) Other primary headaches  Secondary headaches Caused by another disorder Includes cervicogenic headache

3.  Ranked 19 by the WHO among all diseases worldwide causing disability  Thought to be a neurovascular pain syndrome  Triggers include: red wine, skipping meals, excessive afferent stimuli, stress, hormonal changes, sleep depreviation  Two major sub-types: 1) Migraine without aura 2) Migraine with aura

4.  Recurrent headache disorder manifesting in attacks lasting 4-72 hours  Unilateral location,  Pulsating quality  Moderate or severe pain intensity  Agg by routine physical activity eg walking  During HA one of the following: 1) Nausea and or/vomitting 2) Photophobia and phonophobia

5.  Recurrent disorder manifesting in attacks of reversible focal neurological symptoms (develop 5-20mins, <60mins)  Aura consisting of one of the following: 1) Visual symptoms 2) Sensory symptoms 3) Dysphasic speech disturbance  Headache with features of migraine without aura usually follows aura symptoms

6.  Elimination of triggers  Stress coping strategies  Mild attacks: NSAID’s or acetaminophen Mild analgesics containing opoids, caffeine are helpful for infrequent attacks (can be overused)  Severe attacks: Triptans (specifically block the release of vasoactive neuropeptides that trigger migraine pain)  Preventative: Amytriptyline

7.  Very common but little research  Can be episodic or chronic  Mild generalised pain  Does not worsen with activity  No nausea or vomiting  Exact mechanism unknown

8.  Episodes of headache lasting minutes to days  Bilateral location (usually occipital/frontal region)  Pressing or tightening in quality  Mild to moderate intensity  May have photophobia or phonophobia  Typically start hours after wakening and worsen as day progresses

9.  Headache occuring on >15days per month on average for >3months  Headache lasts hours or may be continuous  Bilateral location (usually occipital or frontal region)  Pressing/tightening quality  Mild or moderate intensity  May have photophobia or phonophobia

10.  Analgesics eg asprin  Preventative: Amitriptyline  Relaxation and stress management  Manual therapy

11.  Usually affects men, typically at age of 20-40  Vascular headache- causing dilation of blood vessels which creates pressure on trigeminal nerve  Hypothalamus involvement  Severe unilateral orbital, supraorbital or temporal pain  Lasts 15-180 mins  Occurs from one every other day up to 8 times a day  Ipsilateral autonomic symptoms: nasal congestions, rhionrrhea, lacrimation, facial flushing, horners syndrome

12.  For attacks: triptans  Long term: Verapamill, lithium  Frequent, severe attacks: Prednisone(used to treat inflammatory diseases),Greater occipital nerve block

13.  The pathogenesis of these headaches is still poorly understood  Thunderclap headaches: high intensity headache, <1min  Stabbing headache: ice prick pains, jabs and jolts  Cough headache: precipitated by coughing or straining 1sec-30mins  Exertional headache: Precipitating any form of exercise, 5mins-48 hours

14.  Another disorder known to be able to cause headache has been demonstrated  HA greatly reduced after successful treatment or spontaneous remission of the causative disorder

15.  HA attributed to head or neck trauma  HA attributed to cranial or cervical vascular disorder eg TIA, haemorrage, arteritis  HA attributed to non-vascular intracranial disorders eg intracranial neoplasm, high CSF, epileptic seizure  HA attributed to substance or its withdrawal eg acute substance overuse, medication overuse  HA attributed to infection eg intracranial, systemic, HIV/Aids

16.  HA attributed to disorder of homoeostasis eg hypoxia, hypertension, hypothyroidism, fasting  HA attributed to disorder of cranium, neck, eyes, ear, nose, sinus, teeth, jaw, mouth eg Cervicogenic HA  HA attributed to disorder of cranial bone

17.  Pain referred from a source in the neck and perceived in one or more regions of the head or face  Precipitation of HA by: 1) Neck movement or sustained awkward head postures 2) External pressure over the upper csp or occipital region  Restriction of range of motion in the neck  Unilateral HA’s, originating post and migrating to front

18.  Results from a convergence of sensory input from the upper cervical spine into the trigeminal spinal nucleus  Trigeminocervical nucleus- region of upper cervical spinal cord where sensory nerve fibres in the descending tract of the trigeminal nerve interact with sensory fibres from upper cervical roots.

20.  Input from these areas can have an affect on the trigeminocervical nucleus: 1) Upper cervical facets 2) Upper cervical muscles 3) C2-3 IV disc 4) Vertebral and internal carotid arteries 5) Dura mater of the spinal cord 6) Posterior cranial fossa

21. 1) Forward head posture: increases stress on upper cervical segments 2) Decreases in active ROM in csp 3) Hypertonicity of SCM, UFT, scalenes, sub- occipitals, pect minor, pect major, lev scap 4) Weak deep cervical flexors 5) Poor diaphramatic breathing- causing overuse of accessory muscles of respiration 6) Palpable joint dysfunction

22.  Regular overuse for >3months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache  Peculiar pattern with characteristics shifting from migraine like to tension-like headache  Analgesics  Ergotamine (migraine)  Triptan (migraine and tension type)  Opioid (opioid dependence; withdrawal syndrome  http://www.bbc.co.uk/news/health-19622016