The Role of Manual Therapy in Headache Management

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The Role of Manual Therapy in Headache Management

• Alison Sentance
• Headache Physiotherapy Practitioner
• St Georges Healthcare NHS Trust

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Plan

• Define manual therapy
• Manual therapy to the upper cervical spine
• Manual therapy to the thoracic spine
• The role of a neutral posture
• Conservative treatment contribution to tension
  type headache
• Contribution to management of migraine

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Manual Therapy

• Encompasses the treatment of health ailments of
  various aetiologies through hands on physical
  intervention.
• This form of physical treatment includes soft
  tissue mobilisation, various soft tissue
  techniques, myofascial release, craniosacral
  techniques, mobilisation of the joints, joint
  manipulation, neural tissue mobilisation and
  visceral mobilisation
• RefWickipedia

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Conservative management includes

• Manual therapy to the joints
• Upper cervical spine
• Thoracic spine
• Myofascial treatment
• Postural correction and ergonomic advice
• Relaxation techniques
• Recognition of triggers

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C0-3

• Headache can arise from dysfunction in the
  structures comprising C0-1,1-2 or 2-3.
• Joint dysfunction gives rise to a typical site of
  symptoms for each level.
• Reproducing symptoms from any joint and
  sustaining the pressure can help to relieve
  symptoms.

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C0-1 typical distribution
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C1-2 typical distribution
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C2-3 typical distribution
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We can palpate

• The central intervertebral joint
• The facet joints
• Angle force cephalad or caudad to implicate a
  specific level
• Add cervical spine rotation to implicate a
  specific culprit level
• Palpate in prone or supine lying or sitting
• Extend palpation techniques to treatment

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Pathophysiology of headache

• The neuroanatomical basis for cervicogenic
  headache is convergence in the trigeminocervical
  nucleus (TCN) of nococeptive afferents from the
  receptive fields of cervical nerves 1-3 and from
  the field of the trigeminal nerve
• There is failure of the CNS to differentiate the
  source of pain and misinterpretation of afferent
  information

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More Neurophysiology..

• Plus serotinergic inhibition of nociceptive
  information in the TCN
• Acceptance of the continuum model rather than
  separate headache forms
• A move to encompass the vascular theory into the
  neuronal theory of abnormal nociceptive
  processing in the TCN

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Why is this important?

• If the TCN is oversensitive and sensitised, any
  means that lowers this hypersensitivity will
  result in improvement in headache, what ever the
  headache type, triggers and aetiology.
• Cady,R et al Primary Headaches a Convergence
  Hypothesis.Headache 2002 42 204-16
• Kaube,H et al Acute Migraine Headache. Possible
  Sensitisation of Neurons in the Spinal Trigeminal
  Nucleus? Neurology 2002 58 1234-1238

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Red Flags in Headache

• New onset of new headache in middle age or
  significant change to existing headache
• Constant, unremitting headache
• Headache associated with pyrexia, vomiting not
  explained by systemic disease eg flu
• Recent headache following trauma

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More red flags

• New headache with distal spinal pain
• New headache with a family history of vascular
  anomalies
• New headache with a past history of malignancy
• New onset of migrainous headache in pregnancy

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Differential diagnosis

• Subarachnoid haemorrhage
• Cerebral metastasis
• Intracranial tumour
• Hypertension (BIH)
• Temporal arteritis

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Headache SNAG

• Sustained natural apophyseal glide
• Directed towards C1-2 dysfunction
• Patient must be experiencing symptoms at the time
  of treatment
• Symptoms must be reduced immediately for
  technique to be effective
• Patient can learn to self apply technique

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Treatment of the Thoracic spine

• Generally higher levels hypomobile and
  dysfunctional
• Can address the intervertebral, facet and rib
  joints
• May be dysfunction in the autonomic nervous
  system that can be improved by spinal
  mobilisation
• Aim to restore upper thoracic mobility and a
  neutral thoracic kyphosis in sitting

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Neutral Posture
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Aim to

• Give patients an awareness of sitting/standing in
  a neutral posture
• Explain why they should aspire to this
• Teach them the means by which they can achieve
  this
• Encourage and motivate for at least 3 months

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Cranio cervical flexor training

• Evidence shows that low load endurance exercises
  can retrain muscle control of the cervicoscapular
  and craniocervical regions.
• This addresses the impairment in the neck flexor
  synergy found in headache originating in the
  cervical spine and in tension type headache.

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Deep Neck Flexor retraining

• Start in lying, teach carefully, small amplitude
  movement
• Avoid overuse of Sternocleidomastoid and other
  substitution strategies
• Progress to training in weight bearing, more
  functional positions

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Evidence for CCF retraining

• Non invasive physical treatments for
  chronic/recurrent headache
• G Bronfort, N Nilsson, R Evans, Ch Goldsmith, WJJ
  Assendelft, LM Boulter
• Cochrane Database of Systematic Reviews 2007
  Issue 1
• For cervicogenic headache, there is evidence that
  both low intensity endurance training and spinal
  manipulation are effective in the short and long
  term

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Cephalalgia Vol 26 Page 983 August 2006H van
Ettekoven C Lucas

• Efficacy of physiotherapy including a
  craniocervical training programme for tension
  type headache a randomised clinical trial
• At 6 months follow up, the CCF training group
  showed significantly reduced headache frequency,
  intensity duration.

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Role in management of TTH

• Myogenic rehabilitation
• Postural advice
• Stress management advice
• Advocating relaxation techniques
• Visualisation
• Contract relax techniques
• yoga / pilates

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Evaluating muscle lengths

• Look at
• Upper Trapezius
• Levator scapulae
• Scalenes
• Relative strength of Lower Trapezius, Pec major gt
  minor

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Techniques include

• Self stretches
• Muscle energy techniques
• Trigger point treatment
• Scapular myofascial rehabilitation

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Upper Trapezius

• Stretch by anchoring arm
• Contralateral side flexion
• Hold 15-30 seconds
• Maintain a neutral posture

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Scalenes

• Anterior contralateral side flexion plus
  ipsilateral rotation
• Middle contralateral side flexion only
• Posterior contralateral side flexion plus
  contralateral rotation

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Levator scapulae

• Evaluate length and teach patient to stretch by
  adding
• Neck flexion to
• Contralateral rotation

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Contribution to management of migraine

• Discussion of relevant triggers
• Stress management
• Role of cardio vascular fitness and importance
  of exercise
• Must be tailored to patients lifestyle and
  capability

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Common Migraine Triggers

• Stress or tension
• Dietary alcohol, caffeine, dairy, citrus
• Hormonal variations in women
• Sleeping pattern
• Visual factors harsh strip lights, flickering
• Head or neck pain

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In summary

• This is a fascinating clinical area
• Consider treating headache patients who dont
  appear to have a frank musculoskeletal cervical
  component
• Be aware of cervical arterial dysfunction

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Thank you

• Any questions?
• Useful websites
• www.bash.org.uk
• www.migrainetrust.org.uk
• www.ouchuk.org
• www.worldheadachealliance.org
• www.i-h-s.org

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References

• Recruitment of Deep Cervical Flexor Muscles
  During a Postural Correction Exercise Performed
  in Sitting Falla,D et al Man Ther 12(07) 139-143
• Management of Cervicogenic Headache Jull,G Man
  Ther 1997 2(4) 182-190

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References

• Cervical Arterial Dysfunction Assessment and
  Manual Therapy Kerry,R Taylor A Man Ther 11
  2006 243-253
• Muscle Specificity in Tests of Cervical Flexor
  Muscle Performance OLeary,S et al J
  Electromyography Kinesiology Feb 07 Vol 17
  Issue 1 35-40
• Specificity in Retraining Craniocervical Muscle
  Performance OLeary,S J Orth Sports Phys Ther Vol
  37 No1 Jan 2007 3-9
• Craniocervical Muscle Impairment at Maximal,
  Moderate and Low Loads as a Feature of Neck Pain
  OLeary,S et al Man Ther 12 2007 34-39
• Myofascial Trigger Points in Subjects Presenting
  with Mechanical Neck Pain a Blinded, Controlled
  Study. Fernandez-de-las-penas,F et al Man Ther
  12 2007 29-33
• Myofascial Trigger Points in Suboccipital Muscles
  in Episodic Tension Type Headache.
  Fernandez-de-las-penas,C et al Man Ther 11 2006
  225-230

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References

• Abstract 2816 Special Interest Report Platform
  Presentation No 2816 Physio 2007 93 (51)
• Cervicotrigeminal Pain Mechanisms and
  Management. Valori,A BASH Newsletter Vol1 Issue3
  4-5
• Clinical Tests of Musculoskeletal Dysfunction in
  the Diagnosis of Cervicogenic Headache. Zito,G et
  al Man Ther 11 2006 118-129