HEADACHES

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HEADACHES

• Understand the definition of migraine and other
  headache diagnoses.

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Primary Headache/Secondary Headache

• Primary Headache migraine is an illness, not a
  symptom of another disorder
• Secondary Headache headache that is caused by
  another disorder or is the symptom of another
  underlying condition, such sinus headache,
  cervicogenic, post traumatic headache, tumor
  headache

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Primary Migraines/Headaches

• Usually begin in childhood or early adult life
• History is important
• Location of pain
• Duration of pain
• Frequency and timing of attacks
• Pain severity and quality
• Associated features
• Aggravating and relieving factor

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Primary Headaches Classification

• Migraine
• Tension Type Headache
• Cluster Headache and Trigeminal Automonic
  Cephalalgia
• Other Primary Headaches

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Headaches Location of pain

• Migraine unilateral
• Tension Headache bilateral
• Cluster Headache unilateral, with pain centered
  the eye, check and temple area

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Frequency and Timing of Attacks

• Migraine 5 attacks, 4 72 hours
• Migraine with aura 2 attacks, 4 72 hours
• Tension 10 episodes, 30 minutes to 7 days
• Cluster 5 attacks, one every other day to 8 x a
  day, 15 180 minutes

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Pain Severity and Quality

• Migraine severe, pulsating and throbbing
• Tension mild to moderate, pressing or
  tightening, dull and band like
• Cluster severe, deep, boring, or piercing like
  a red hot poker thrust into eye

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Associated Features

• Migraine
• Nausea
• Vomiting
• Photophobia heightened sensitivity to
  light
• Phonophobia heightened sensitivity to
  sound
• MUST HAVE ONE TO BE DIAGNOSED MIGRAINE
• Tension
• No nausea /vomiting
• No or one photophobia/phonophobia

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Four Phases of Migraine

• Prodrome (preheadache warning)- minutes to hours
  prior to headache, psychological and physical
  changes including mood, elation, irritability,
  depression, fluid retention, thirst and food
  cravings varied energy levels
• Aura fully reversible visual symptoms, sensory
  symptoms and/or speed disturbances
• Headache unilateral, pulsating,
  moderate/severe, cannot do activity, nausea,
  vomiting, photophobia, phonophobia
• Postdrome (post-headache)- 24 hour period after
  the headache, exhaustion, fatigue, and emotional
  change

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AURA PATTERNS

• Visual Aura scintillating scotoma, a bright
  area of flashing lights that expands over one
  side of visual field, about 20 minutes (positive
  features), tiny floaters to dramatic
  hallucinations
• Scotoma area of decreased vision (black,
  gray, white or clear) (negative features)
• Phosphenes bright flashes of light
• Sensory Aura tingling (positive) or numbness
  (negative), typically in one hand or near the
  lips on one side, can spread to arm
• Aphasic Aura inability to speak
• Motor Aura weakness on one side of body

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Migraine

• Migraine without aura
• Mirgraine with aura
• Typical aura with migraine headache
• Typical aura with nonmigraine
• headache
• Typical aura without headache
• If migraine headache is during the aura or
  within 60 minutes, it is still migraine with
  aura.

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Migraine with aura and motor weakness

• Familial hemiplegic migraine migraine with
  aura including motor weakness and at least one
  first or second degree relative has condition
• Sporadic hemiplegic migraine migraine with
  aura, including motor weakness and no family
  history

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Basilar Migraine

• Basilar type migraine from brainstem or both
  hemispheres, aura greater than 5 minutes to 60
  minutes and two of following fully reversible
  symptoms
• visual symptoms both eyes at same time
• ataxia
• bilateral paresthesia
• dysarthria
• vertigo
• tinnitus
• hypoacusia
• diplopia
• decreased levels of consciousness

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Tension Type Headache

• Infrequent - lt one a month, lt 12 a year
• - 30 minutes to seven days
• Frequent - gt one day a month, lt 15 a month
• - 30 minutes to seven days
• Chronic - gt 15 a month
• - hours or continuous

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CLUSTER HEADACHE

• 5 attacks
• One every other day to 8 x a day
• Severe, unilateral
• Supraorbital and/or temporal
• Lasts 15 180 minutes
• Accompanied by one of the following

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CLUSTER HEADACHE

• Cluster headache must be accompanied with one of
  the following
• Ipsilateral conjunctival injection and/or
  lacrimation
• Ipsilateral nasal congestion and/or rhinorrhoea
• Ipsilateral eyelid oedema
• Ipsilateral forehead or facial sweating
• Ipsilateral miosis and/or ptosis
• Sense of restlessness of agitation

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CLUSTER HEADACHE

• Episodic cluster a least two cluster periods,
  lasting 7 365 days, separated by pain free
  remission periods of gt one month
• Chronic cluster headache attacks occur over gt
  one year without remission periods or with
  remission periods lasting lt one month

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Cluster Headache

• Generally men
• Attacks occur at the same time every day
• Agitation , pace, rock back and forth

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CLUSTER -Paroxysmal hemicrania

• Rare cluster headache, 20 attacks
• Like cluster headache, but briefer, 2 30
  minutes, and more frequent, gt5 a day
• More common in female
• Prevented completely by indomethacin

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CLUSTER - SUNCT

• Short lasting unilateral neuralgiform headache
  attacks with conjunctival injection and tearing
  (SUNCT)
• Short lasting attacks of unilateral orbital,
  supraorbital, or temporal stabbing, pulsating
  pain lasting 5- 240 seconds
• 2 300 x a day
• Ipsilateral conjunctival injection and
  lacrimation
• Lesions in the posterior fossa or involve
  pituitary gland

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CRONIC DAILY HEADACHE

• Four Types
• Chronic Tension Type Headache
• Chronic Migraine or Transformed Migraine
• Rebound or analgesic overuse headache
• Pattern of worsening or more frequent HA
• Severe HA within days of discontinuing acute HA
  med
• Increase in amount of medication you are taking
• Preventative meds or previous treatment no longer
  works
• New Daily Persistent Headache
• Chronic pattern that develops suddenly
• Linked to virus
• Linked to surgery to another part of body
• Hemicrania continua
• Features of migraine and cluster (sand in eye)
• Responds to indomethacin
• All occur more than 15 days a month and last more
  than hours a day.

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Trigger Factors

• Trigger factors increase the probability of
  migraine attack in the short term (usually less
  than 48 hours.
• Hormonal
• Menstruation
• Diet
• Hunger, alcohol, additives, certain foods
• Physical Exertion
• Sex, exercise

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Aggravating Factors

• Particular factors that may be associated with a
  relatively long-term (usually weeks to months)
  increase in the severity and frequency of
  attacks.
• Psychological stress
• Alcoholism
• Environmental factors

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Secondary Headaches

• Head and/or Neck Trauma
• Cranial and Cervical Vascular Disorder
• Non-vascular Intracranial Disorder
• Substance or its withdrawl
• Infection
• Homeostasis
• Psychiatric Disorders

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Secondary Headaches

• Characteristics of the headache itself or poorly
  described in the scientific literature.
• Few diagnostically important features
• Patient can have a Primary Headache and a
  Secondary headache diagnosis. The secondary HA
  diagnosis is added when there is close temporal
  relation and marked worsening of the primary HA.
• Evidence that other disorder can aggravate the
  primary HA and remission of primary HA after cure
  or remission of other disorder.

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International Classification of Headache
Disorders

• Category 11
• Headache or facial pain attributed to
  disorders of cranium, neck, eyes, ears, nose,
  sinuses, teeth, mouth, or other facial or cranial
  structures.
• 11.1 Headache attributed to disorder of the
  cranial bone
• 11.2 Headache attributed to disorder of
  neck cervicogenic headache
• retropharyngeal tendonitis
• craniocervical dystonia

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11 Eyes, Ears, Nose/Sinus

• 11.3 Headaches attributed to disorders of the
  eyes
• 11.4 Headaches attributed to disorders of the
  ears
• 11. 5 Headaches attributed to disorders of the
  rhinosinusitis

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MORE 11

• 11.6 Headache attributed to disorder of
  teeth, jaw, or related structures11.7 Headache
  or facial pain attributed to TMJ disorder11.8
  Headache attributed to disorder of cranium, neck,
  eyes, nose, sinuses, teeth, mouth, or facial or
  cervical structures11.9 Chronic post
  craniocervical disorder headache

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11.2.1Cervicogenic Headache11.2.1.1 associated
with myofascial tender spots

• Pain, referred from a source in the neck and
  perceived in one or more regions of the head and
  or face.
• Clinical, laboratory, and/or imaging evidence of
  a disorder or lesion within the cervical spine or
  soft tissue of the neck, accepted as a valid
  cause of headache.few demonstrated with
  reliability and validity
• Clinical signs that implicate a source of pain in
  the neck
• movements of neck positions. (clinical signs
  of provocation)
• Abolition of headache after diagnostic blockade
  of cervical structure
• Decreased neck motion and sensitive neck
  muscles.

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Causes Cervicogenic Headache

• Hypermobility
• Trauma
• Overuse
• Developmental Anomalies (Arnold-Chiari)
• RA, Osteomyelitis, Dystonia

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Headache attributed to disorders of the teeth and
jaws or related structures

• HA accompained by teeth and/ or jaw pain
• Evidence disorder of teeth, jaws and related
  structures

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HA attributed to TMJ disorder

• Pain in head and/or face
• Xray, MRI and or bone study demonstrates TMJ
  disorder
• Pain with jaw movements and/or chewing
• Reduced jaw opening
• Noise in one or both TMJ
• Tender TMJ Joint capsule(s)

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Headache Alarms

• Sudden thunderclap headache
• Marked change in headache pattern, such as
  increased frequency, intensity, duration
• Neurological signs, such as double vision,
  blindness, confusion, dizziness, weakness, or
  sensory loss
• Severely stiff neck or spike of pain with quick
  movements of head
• Weakness on one side of body
• Persistent unexplained vomiting
• Blood pressure higher than 180/115
• Over 50 and just started having headaches

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Cause of Migraine Multiple causes

• Visual part of migraineurs brain is
  hypersensitive
• Aura is caused by a wave of increased electrical
  activity that moves across the brain, followed by
  loss of activity, increased blood flow then
  decreased
• One or more areas or activated during a migraine
  migraine generator
• The covering of brain (meninges) and blood
  vessels are inflammed. Nerve endings secrete
  inflammatory proteins around meninges.
• Migraine attacks there is sensitivity to normally
  nonpainful stimulation of the scalp or other
  parts of head and even arm called allodynia.
  Allyodynia develops after migraine starts and
  usually one to four hours later. Once starts,
  migraine more difficult to treat.

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Peripheral Factors for Migraines

• Trigger points in muscle send pain stimulus to
  central brain
• Central brain become hypersensitive to any
  stimulation and more easily triggered
• Elimination of peripheral trigger point can
  reduce the primary migraine trigger

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Biomechanical Causes of Headaches

• Myofascial Pain Dysfunction
• Trigger point referred pain
• Cervical Spine Dysfunction
• Rotated upper cervical vertebrae
• Upper cervical loss of functional space
• Loss of cervical lordosis
• Upper cervical nerve root referrals

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Managing Headaches

• Physician Patient Communication
• Education about headache diagnosis, what symptoms
  mean, and treatment plan
• Motivate lifestyle change and manage problem
• Headache specialist manage medications,
  realistic expectation for both acute and
  preventative medications
• Primary headaches are controlled, not cured
• Physical therapy for primary and secondary
  headaches

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Cont. Managing Headaches

• Trigger identification
• Headache calendar duration/intensity and Rx
• Abortive and preventative medication
• Non medication type treatment, like physical
  therapy and biofeedback.
• Smoking cessation and exercise
• Regular routine
• Depression and anxiety make HA more difficult to
  treat
• Your own health - Locus of control
• Doctor
• Be in charge of your health
• Reduce chaotic factors that affect health

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Live life at ease

• Call 216-682-0413 for an appointment at the Head,
  Neck, and Facial Pain Therapy Center.
• Take your first step to easing your pain.
• Your first appointment will include a
  comprehensive craniomandibular cervical exam and
  treatment.