In this blog, we’re going to dive into the topic of headaches. We’ll take a closer look at the types of headaches and their impact. This will involve examination of migraines, tension-type headaches and cervicogenic (related to neck tightness/pain) headaches. From here we'll look at treatment options, including physiotherapy.
TYPES OF HEADACHES
Before looking at the impact of headaches and migraines, it is worth understanding some of the different types of headache. The International Headache Society (IHS) describe a remarkably extensive list of the types of headache, so in the interest of brevity, the main categories and types will be looked at.
The IHS divides headaches into two main categories; Primary and Secondary.
1. Primary Headaches
Primary headaches generally are those not attributed directly to an underlying condition, whilst secondary headaches are caused by another disorder. The main primary headache types include; migraines, tension-type headache and cluster headaches.
Migraines are a particularly disabling subset of primary headaches which can present with or without aura. Aura involves neurological symptoms, commonly occurring for around one hour before the onset of a migraine. These symptoms can include, but are not limited to, visual disturbances such as flashing lights, blind spots, fortification spectrum (zig-zag lines appearing at points of focus) as well as dizziness, pins and needles, numbness and photophobia (sensitivity to light).
In some instances, migraines with or without aura may be associated with a premonitory period. These are a collection of symptoms, which are differentiated from auras in that they typically present hours to days before the onset of migraine. Symptoms can include fatigue, nausea, sensitivity to sound or light as well as neck tightness/pain.
Chronic migraines can also develop when headaches are experienced over 15 days per month, with at least half being migraines. Migraines can also be triggered, exist prior to, or be otherwise associated with, other types of headaches, most commonly medication overuse and cervicogenic headaches.
Tension-type headaches are a prevalent sub-set of primary headaches. These headaches are common and are divided by the IHS into episodic and chronic tension-type headaches.
Episodic tension-type headaches generally involve a ‘tightening’ or ‘pressure’ sensation of mild to moderate intensity lasting a few minutes to days. Chronic tension-type headaches present similarly, although are particularly detrimental to quality of life and disability due to their capacity to last hours to days and even constantly. The symptoms can present similarly to mild migraines (including light and sound sensitivity) making diagnosis at times challenging.
2. Secondary headaches
Secondary Headaches generally are caused by an underlying condition or disorder. These headaches can be secondary to causes such as; neck tightness, head trauma, vascular disorders, medication overuse and infections amongst many others.
Cervicogenic headaches are headaches referring from the neck. They are typically categorised by the reproduction of headache symptoms with manual pressure on areas of the neck, as well headache symptoms generally beginning from the back of the head and moving to the front. It’s most commonly caused by degenerative changes in the joints of the upper neck or muscular dysfunction of the neck and surrounding muscles. Due to the neck being the source of the headache, cervicogenic headaches are often associated with neck tightness and joint stiffness producing reduced range of motion.
PHYSIOLOGY OF HEADACHES
The underlying processes of headaches, particularly migraines, are not fully understood, however general theories revolve around the concept of a dysfunction in the processes carried out by the brainstem. The brainstem acts as a modulator of sensations the body receives, such as light, sound, smell, touch and pain. It is theorised in headaches, specifically migraines, the brainstem begins to modulate these normally harmless sensations, as sensations of pain (known as ‘allodynia’), explaining the commonly associated light and sound sensitivity.
The cause of these changes is yet to be determined, although recent studies suggest various potential contributors in a complex association between genetic and environmental factors. For example, associations have been found between migraines and changes in function of calcium channels secondary to genetic changes, acting as a potential contributing factor, as well as environmental factors, such as the association found between chronic headache onset and childhood trauma.
Impact of Headaches
Despite the uncertainty regarding the physiology of headaches, their impact is unquestionable, both at an individual and global level.
As one of the most common types of everyday pain, headaches have a significant prevalence, with studies suggesting tension-type headaches alone affecting one in ten people on a weekly basis and migraines being the second largest cause of disability worldwide. Overall, an estimated 3 billion people experienced a headache disorder in the year 2016, of which 1.89 billion experienced tension type headaches and 1.04 billion suffering migraines with an economic cost of $35.7 billion per annum in Australia alone.
At an individual level, migraine sufferers commonly experience decreased quality of life, particularly due to their association with depression. Furthermore, sleep quality is often affected, with studies finding migraines and tension-type headaches to be associated with increased sleep disturbances. Vice versa, a lack of sleep can also trigger headache symptoms promoting a vicious cycle which can present as a risk factor in the progress from episodic to chronic symptoms.
Headache management can often be quite challenging, particularly due to the limitations of the understanding of the processes behind them. For this reason, the principles of managing headaches, particularly migraines, are based around a multi-modal approach of medication, complementary therapies, lifestyle modification, and, particularly in the case of cervicogenic headaches, physiotherapy and exercise which can be guided with the assistance of a doctor, specialist and/or physiotherapist.
Medication is a common point of call for treatment after an acute headache and generally considered the first line treatment choice for acute migraine attacks. This can include simple analgesics and anti-inflammatories. Although, there is also evidence suggesting the effectiveness of a group of medications known as ‘Triptans’, particularly for the treatment of migraines. Despite the encouraging effectiveness of medication, as mentioned previously, medication-overuse headaches are another category of headache that can arise from dependence on acute medication, and contribute to increased frequency of headaches. In these instances, preventative medication is often sought to lessen the impact of medication-overuse headaches, with medications of choice including beta-blockers, anti-depressants and anti-convulsants, amongst others.
Trigger Identification and Lifestyle Modification
Monitoring potential triggers is an effective way to manage headache and migraine symptoms, with the use of a diary or calendar to aid. Precipitating factors vary, but can include dietary trigger (such as missed meals, dehydration or specific foods), environmental triggers (bright lights, perfumes, weather changes) or hormonal changes (pregnancy or menstruation) as well as lack of sleep, neck pain or stress. Acting to limit triggers generally results in lifestyle modifications to keep symptoms at bay. This includes managing stressors (work, finances, exercise), diet and maintaining routine.
Physiotherapists can play an integral role in headache management, functioning within a multi-disciplinary approach, particularly in the case of chronic headaches. It can assist in managing pain associated with headaches as well as neck pain.
Physiotherapy can also assist in decreasing the reliance on medication by serving as an alternative/complementary option to manage symptoms. Establishing a positive physiotherapist-patient relationship can assist in long-term individualised management of headaches through monitoring of symptoms, discussion of treatment options and setting short and long-term goals.
1) Neck and Shoulder Dysfunction
Physiotherapy can also be effective in managing shoulder and neck dysfunction associated with headaches. Neck pain and tightness can cause, precipitate or be the consequence of headaches, making it a common focus for physiotherapy. Treatment aims to address the muscle tension and joint stiffness at the head and neck using a combination of muscle activation, strengthening and stretching exercises. This also includes general shoulder strengthening and ergonomic correction, focusing on sitting position awareness and posture correction exercises. These exercises aim to improve long-term outcomes, and also can provide short-term relief.
2) General Exercise
General exercise has also been found to be effective to combat a vicious cycle whereby the onset of migraine contributes to an inability to carry out physical activity, and this physical inactivity may increase the severity, frequency and duration of migraines, further restricting the ability to exercise. It is important to monitor and keep track of the response to exercise in terms of migraine intensity, duration and frequency, as occasionally exercise can present as a triggering factor for migraines.
3) Manual Treatment
Manual therapy is another option in physiotherapy which has shown to have some effect on reducing the frequency, intensity and duration of tension-type headaches, migraines and cervicogenic headaches, particularly with trigger point therapy.This also includes addressing upper neck joint stiffness by mobilisation of the joint and observing for referral patterns to the head.
The use of ice and cold therapy can improve pain levels once a headache has begun, particularly when applied at the neck. Other alternative therapies which have shown some positive effective include acupuncture, massage, yoga and meditation potentially due to the positive effect on pain levels as well as stress levels, which can serve as a precipitator and aggravator to headaches.
In cases of chronic migraines, use of Botulinum toxin type A or Botox Therapy, can be considered for particular cases and has shown some shown effect in reducing the severity and frequency of migraines and improving quality of life.This is thought to be due to the ability for it to inhibit overactive muscles in the head which appear to have a role in contributing towards migraines. There are also suggestions that Botox therapy inhibits pain pathways in the body’s sensory system, although the underlying processes are yet to be clarified.
Headaches can be complex, and despite the ongoing research, many of the specifics of the underlying processes of headaches still remain unclear, and its management likewise. Nonetheless, the body of evidence available appears to encourage a multi-disciplinary approach to management with an emphasis on a trusting patient-practitioner relationship whereby treatment options of medication, physiotherapy and other management options can be explored effectively for optimal long-term outcomes.
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