MISCP MCSP MMACP. Chartered Physiotherapist specialising in treating Sports & Musculoskeletal Disorders

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1 MISCP MCSP MMACP Chartered Physiotherapist specialising in treating Sports & Musculoskeletal Disorders

2 Physiotherapy Treatment of Migraine

3 Classification of headaches Primary Pain felt in the head from a source in the head Tension type Headache 50-80% prevelance Migraine with or without aura 10-12% Chronic Daily headache 3% Cluster 0.5% Secondary Pain felt in the head has a cause Dissection, neoplasm Medication overuse Cervicogenic headache

4 Headache or Migraine All headaches have a common anatomy and physiology All headaches are mediated by the Trigeminocervical nucleus (TCN)

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6 Trigeminocervical Nucleus Is a region of grey matter within the brainstem It is causally continuous with the grey matter of the spinal cord TCN is defined by it s afferents

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11 Trigeminocervical Nucleus (afferents) Trigeminal nerve (cranial v) Upper 3 cervical levels Facial nerve (vii) Glossopharyngeal nerve (ix) Vagus nerve (x) All of these sources of afferents terminate on common second order neurons in the TCN

12 TCN The TCN is the sole nociceptive nucleus of the head, throat and upper neck. Trigeminal nerve afferents will descend to the level of C3 and perhaps as low as C4. Because the opthalmic branch of the trigeminal nerve extends the farthest into the TCN, cervical afferent stimulation is most likely to refer pain to the frontal-orbital region of the head.

13 Convergence Hypothesis Successive symptoms experienced clinically reflect an escalating pathophysiological Sensitisation process Tth is the early manifestation of this process If the process continues uninterrupted increasingly severe headache develops into migraine Cady et al 2002

14 Physiotherapy & Headache Which headaches require a physiotherapy assessment? What can physiotherapy do for headaches? Has physiotherapy been proven to be successful?

15 There s nothing wrong with her neck - her earrings are too heavy!

16 Which Headaches might a physiotherapist be able to assist with? Tension type headache Cervicogenic headache Migraine with neck as a trigger

17 Tension Type Headache(TTH) Episodic < 15 days a month Chronic > 15 days a month Headache lasts 30 minutes to 7 days Characterised by bilateral pressing or tightening head pain No significant associated symptoms The international classification of headache disorders 2 nd edition 2004

18 Muscle tenderness in TTH Tenderness of neck & shoulder are common 20 muscles can refer pain to the head Myofascial trigger point Hyperirritable spot in a taut band of muscle Perpetuating factors such as injury or overload Worsened by stress

19 Trigger Points

20 Evidence 100% of people with chronic TTH have TrP in suboccipital muscles Nociceptive afferent input through Trigeminal nucleus Dura (rcpmnr) Fernandez-de-las-Penas et al Trigger points in sub-occipital muscles & forward head position in tension type headaches Headache :

21 How does Physiotherapy help with TTH? Education/prevention of aggravating postures Manual therapy of trigger points Stretching & movement exercises Strengthening of core postural muscles

22 Cervicogenic Headache CeH First diagnostic criteria in 1983 Included in HIS in 2004 Remains disputed by many neurologists Goadsby PJ Cervicogenic headache a pain in the neck for some neurologists The Lancet 2009

23 Cervicogenic Headache Secondary headache Pain felt in the head from a source in the neck Usually unilateral No defined pattern of frequency, severity or duration Minimal associated features May have a history of neck trauma or poor posture

24 Cervicogenic Headache Need evidence of a cervical spine problem Headache must be reproduced by 1 awkward neck positions &/or 2 physical examination

25 Neurophysiology of CeH Convergence of trigeminal nerve & upper 3 cervical nerves in the trigeminocervical complex of the brainstem

26 Physiotherapy for CeH Thorough history taking Assessment of neck posture, movement & muscle strength Manual examination of painful muscles, joints & nerves that may be acting as a pain source Individual treatment plan

27 Migraine 500,000 sufferers of migraine in Ireland Migraine costs our economy 252 million annually in sick leave & decreased productivity Average migraineur gets 1 attack/month Loses 2 days from work each year & 4 days of decreased effectiveness each year Not counting loss to family & social life

28 Causes of Migraine Exact cause is unknown?trigeminal?vascular 60% is inherited 3 times more common in women than men

29 Migraine-Is it a sensory processing disorder? Migraine is primarily a disorder of sensory processing Information from the trigeminal field is no stronger than normal but the reaction to it in the brainstem is significantly greater, effectively generating pain from almost nothing. Goadsby 2003

30 Primary headache Migraine Disorder of the central nervous system resulting in pain & neurological symptoms Sensitivity of trigeminovascular system Genetic predisposition Attacks normally last 4-72 hours Unilateral, pulsating, moderate to severe pain Associated symptoms, nausea, photophobia, phonophobia

31 Trigger Factors Emotions Change of routine Hormonal Food Sleep Diet Alcohol Exercise Neck

32 I have a terrible ice cream headache all the time

33 Migraine Threshold Migraine Threshold Trigger Factors

34 Threshold Keep a headache Diary Know how many triggers it takes to bring you over your migraine threshold

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36 Migraine & the Neck 60% of people with migraine have neck pain More prevalent than nausea Options: 1 separate migraine & neck pain 2 neck pain is a symptom of migraine 3 neck dysfunction is triggering migraine

37 Physiotherapy & Migraine How an individual migraine sufferer responds to physiotherapy treatment will depend on the extent to which the muscles/joints are involved

38 Physiotherapy for migraine with a possible neck involvement Thorough history taking Rule out red flags, neurological examination Assess posture, neck movement & strength Manual examination of muscles joints & nerves that may be acting as pain source

39 Clues to neck involvement with Neck pain migraine Previous trauma to the neck Poor postures at work or home Awkward neck posture or movement bring on migraine Pressure to back of neck, massage, heat relieving headache

40 Positive signs on neck examination Reproduction & resolution of headache on palpation of upper cervical spine Stiffness & tenderness of joints or muscles with poor posture

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42 C1-C2

43 C2-C3

44 Treatment of neck related migraine Sustained joint mobilisation techniques Muscle release - triggerpoint release & stretching Posture re-education/ ergonomics Specific muscle strengthening Awareness of aggravating factors/triggers

45 Has physiotherapy been proven to work for headaches 2 studies have been done in Australia showing that physiotherapy helps cervicogenic headaches.

46 How effective has physiotherapy been in the treatment of migraine? No research published to date On going audit of patients attending Beaumont Hospital More research needed

47 Audit of Physiotherapist role in Beaumont Migraine Clinic 68 people referred by the team to Julie Sugrue Of these 66% had findings of cervical spine dysfunction & physiotherapy was advised Examination findings included Reproduction of a familiar head pain (69%) Myofascial trigger points (87%) Reduced ROM (84%)

48 Audit of Physiotherapist role in Beaumont Migraine Clinic Out of patients followed up in Beaumont Hospital Average 4 sessions Frequency reduced from 30 to 2 days/month Intensity reduced from 8/10 to 3/10 40% had full resolution of headache

49 Audit of Physiotherapist role in Beaumont Migraine Clinic None of the people had a diagnosis of cervicogenic headache Migraine without aura Mixed (migraine and other headache) Tension type headache

50 Treatment Detailed history of pattern, severity, frequency of headaches Rule out red flags Examine the neck by palpation Reproduction & easing of familiar migraine pain on palpation

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52 Case History Female 57 years Right sided migraine since age 15, eye symptoms is indicative of impending migraine At least 1 migraine/ week for last few years When bad nausea & vomiting Head never clear in last 2 years (pressure in head every morning) Constant varying pain in her upper cervical spine

53 Case History cont Drug treatment 2x Solpadeine & naproxyn at first onset or Zomig Beaumont: Sibelium x1 initially & then up to 2/day (side effects) VAS never 0, varies from 5 up to 10 if doesn t get meds in time. Mother & sister also migraineurs

54 Examination Head forward posture Limited cervical flexion Mild scoliosis convex left upper T spine Poor scap position Doesn t open mouth much when speaking Reproduction & lessening of familiar pain with palpation of upper cervical spine

55 Treatment Posture correction Advice re pillows & sleeping position Manual therapy Exercises for neck ROM and low level strengthening exercises Headache diary

56 Progress Some short periods of head clear after first treatment After 3 treatments had longer gap between migraines Took 6 treatments before significant decrease in frequency of migraines now no Sibelium, migraines about 1/month managed with solpadeine, head clear Maintenance physiotherapy 1 every 3/12

57 Case History 2 Nurse in her 40 s Left sided migraine with her period since aged 14, lasting 2-3 days & can be from 3-7/10 on a pain scale, Right sided migraine started 5 years ago, monthly but not with cycle, can be up to 10, can cause her to miss work, worse if tired or stressed.

58 Headache Diary Night duty A run of long days ½ glass of wine Loud music Identify her triggers: 20 minutes horse riding with head turned to right talking to friend

59 6 Month Progress No days missed from work due to migraine Decreased intake of Zomig Decreased frequency, severity & duration of migraines

60 Outcomes Physiotherapy treatment should be making a difference to either the frequency, duration or intensity of the migraine with 3-4 treatments If not improving any of these then physiotherapy not likely to help May need 6-8 treatments but should get long term improvement in symptoms

61 Can you imagine what it would have been like if I hadn t faked headaches

62 Headache Summary Research suggests that headache & migraine is a common process sharing a common disorder that is a sensitised TCN/brainstem It is reasonable & logical that upper cervical dysfunction has the potential to sensitise the brainstem The trigeminocervical nucleus (TCN)/brainstem is the doorstep of the final common pathway of all headache & migraine information.

63 In summary Use the information from the migraine association Improve your palpation skills of the upper cervical spine. Look out for courses, very few Dean Watson C Fernandez de-las-penas

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