This literature search and review aims to synthesise the evidence and reasoning supporting physical headache treatments.

Transcription

1 UNIVERSITY OF BRIGHTON FACULTY OF HEALTH Module HEM 24 Practice Development through Independent Learning 2011 Dianne Allan Personal tutor: Linda Lovelock Word count: 2, Background Headaches are, by definition, an experience of pain in the head area. Most sensory nerves of the body emerge from segments of the spinal cord but the Trigeminal nerve which covers the head arises directly from the brain as the fifth cranial nerve. The trigeminal nerve communicates with sensory nerves from the upper cervical vertebrae in an area named the cervico-trigeminal nucleus (TCN) (Bogduk, 2001). It is this connection which forms the basis of the theories of the development of cervicogenic headaches (Govind, 2009). The opinions on the extent and importance of this connection are many and varied. There has been extensive research into the pharmaceutical approach including metaanalysis for primary headache management (Ferrari et al., 2002) whereas physical treatment approaches have been less thoroughly investigated. This is illustrated in a revised critical review on the management of cervicogenic headaches (Haldeman and Dagenais, 2001) which found that the treatments by headache clinicians (physical therapists specialising in headache management) were gaining recognition but were often neglected in the spine literature. This literature search and review aims to synthesise the evidence and reasoning supporting physical headache treatments. 2. Approach In mainstream medicine the most usual approach to understanding headaches is to classify them into different categories using the International Classification of Headaches (ICH) (International Headache Society 2008). In this review the ICH is discussed but with the understanding that it is continually being modified and not always accepted by practitioners working in the field of headache treatments. To establish a picture of papers published in this area of physical therapy searches were carried out using the open access scientific search engine Scirius. The search terms used were chronic headaches and therapy and the search was restricted to papers published within the last 10 years. To find the percentage of these chronic headaches which related to the cervical spine it was refined by the terms: AND cervical OR cervicogenic. Page 1 of 9

2 More extensive searches were then undertaken to cover a longer time span and other related subjects for a more in depth exploration. The papers with conflicting results needed to be examined carefully for an understanding into the processes which led to these discrepancies. One of the major areas of debate is the treatment approach to migraine as the aetiology is still unclear (Seneviratne, 2009). Other areas relevant to these searches were temporomandibular and sinus related headaches as they are also covered by the trigeminal nerve for their sensory input. It was decided not to include the temporomandibular joint in this study because the extra joint and muscle factors would warrant a complete study of its own. The sinus related headaches are included because they have direct connections with the TCN similar to other areas of the head. Over 100 abstracts were read and the ones which seemed particularly relevant were accessed in the online resources section of the UOB library, read in full and stored for future reference. These were integrated with books and lecture notes. A cross search was also carried out for primary headaches and cervicogenic headaches to find how these terms are used in the various literature. This revealed fundamental differences so it is necessary to define some of the terms used in this review followed by some reasoning for the choice of definition. 3. Definitions as used in this review 3.1. Primary Headache: This is defined in the Gale Encyclopaedia of Medicine as a headache that is not caused by another disease or medical condition. This implies the cause is either unknown or caused by a factor which cannot be considered a disease or medical condition. It is quite usual for physiotherapists to work on muscle, joint and neurological dysfunctions in the treatment of problems which are not considered as actual diseases or serious medical conditions so treating headaches by working on the cervical spine could be considered part of normal physiotherapy. It follows that the term Primary Headache can still be used for all headaches which do not have some other disease or causal factor which needs medical attention in a similar way to the approach to tennis elbow or repetitive strain injury. In this review all headaches shall be considered as Primary excluding those: 1. Which have been screened for possible serious pathology and so referred on for further investigation e.g. subarachnoid haemorrhage. 2. Resulting from infections e.g. Influenza. 3. Resulting from noxious stimuli e.g. hangover. 3.2.Cervicogenic Headache (CGH): This will include, not only those resulting from more obvious neck injuries and arthritic changes, but more subtle joint hypomobilities and Page 2 of 9

3 muscle imbalances which need not necessarily be experienced by the patient as neck pain. There is a great deal of variation in the perceived prevalence of CGH. These ranged from 0% (Leone et al., 1995) to 80% (Rothbart, 1996) of patients with migraine. This is partly due to the fact that there exists no objective tests to confirm a diagnosis of CGH as the criteria laid down in the IHS rely too much on personal opinion to be objective (Haldeman and Dagenais, 2001). The role of the cervical spine in the development of Primary Headaches is an area of debate as some headache specialists consider the cervical spine is only relevant if there are obvious neck symptoms whereas some believe it is often a key player in the development of many types of primary headache including Migraine (Nelson et al., 1998). This trial compared the results of one type of commonly used medication (Amitriptyline) with a physical therapy (chiropractic) for migraine treatment. Nelson concluded that: Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline). He deduced that input from the cervical spine must be one factor common in the development of this type of Primary Headache Physical Therapy: This mainly refers to physiotherapy but does include papers written by osteopaths and chiropractors when the techniques used could be considered part of physiotherapy. 4. Results and analysis 4.1. Overall statistics chronic headache therapy. 245,534 AND cervical spine OR cervicogenic 16,159 AND migraine 5,515 Considering that the ICH states The contribution of cervical spine disorders to migraine and tension-type headache is poorly understood and estimates CGH to be 14-18% of all headaches (Zito et al., 2006) the cervical spine does not appear to be considered in general research enough to explore the subject thoroughly. The cervical spine is in 6.6% of literature of chronic headache therapy. The cervical spine is in 2.3% of literature of migraine therapy Literature reviewed and analysed The latest National Institute of Clinical Excellence (NICE) Guidelines ( use the ICH (society, 2005) as a framework with an aim of helping the general NHS clinician to Page 3 of 9

4 manage headaches more effectively. There are over 200 categories of headache but some have characteristics of more than one syndrome. One of the aims of the NICE guidelines is to increase the confidence of general practitioners in diagnosing headaches and so finding the most effective therapy without having to refer for unnecessary investigations. The guidelines themselves show inconsistences, for example, their scope does not include treatment for Secondary headaches (in which they include CGH) except for ones from medication overuse. Manual therapies are then recommended in the Other Therapies section for CGH. There is no other mention of physiotherapy which reflects the fact that, out of the 15 on the development group there is only 1 physiotherapist. The 24 specialist reviewers were exclusively from medical, pharmaceutical and dental professions. One interesting statistic from the NICE guidelines is the recognition of the most common cause of daily headaches being overuse of medication. This highlights how therapeutic medication can be misused. An audit was carried out in GP practices to assess the extent of overuse of Triptans which are commonly prescribed for the control of migraine (Williams et al., 2002) and found about 25% were taking high or very high doses. It recommended that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Systemic reviews for physical treatments of headaches generally have inconclusive results (Bronfort et al., 2004) showing only slight benefits of manual therapies over placebo. On analysis of the trials used in these reviews it is necessary to examine their criteria. The trials which show inconclusive evidence for effective physical treatment for headaches often show a lack of understanding of the full scope of physiotherapy and similar interventions. There are often comparisons between scenarios that would not be seen in the practice of an experienced physiotherapist e.g. a comparison between physiotherapy and acupuncture (Carlsson et al., 1990). A physiotherapist who is trained in acupuncture uses this modality as one of the options for many conditions after clinically reasoning its suitability. The concept of giving one group physiotherapy and acupuncture does not allow for the best clinical reasoning processes and so is not a reflection on the full potential of physiotherapy. Similarly a prospective, randomized, placebo-controlled, and blinded trial was run to compare manual therapy with sham manual therapy in adolescents suspected of CVH (Borusiak et al., 2010). This trial showed lack of efficacy of manual therapy. Each adolescent had only one intervention of physical therapy which is not in line with current recommendations of a series of treatments for CGH (Haas et al., 2010). For randomized trials to be meaningful the trials need to meet criteria of quality. A detailed study was carried out in 2006 by a physical therapist to examine the methodological quality of randomized controlled trials of spinal manipulation and mobilization in TTH, migraine and CGH (Fernández-de-las-Peñas et al., 2006). The methodological quality was typically low with no description of the manipulative procedure, small sample size and no proper placebo Page 4 of 9

5 control group. This demonstrates the difficulties in obtaining reliable information from randomised controlled trials in the field of manual treatments. Studies done by physical therapists with specific training in headache management can demonstrate much more positive results: 1. A multicentre, randomised controlled trial with blinded outcome assessment of specialised headache treatments on 81 people with Tension-type headaches(tth) demonstrated the effectiveness of joint mobilisations and craniocervical training programmes (van Ettekoven and Lucas, 2006). Outcome measures included headache frequency, intensity, duration and quality of life. There was more than 50% decrease in uptake of medication at 6 months after the treatments had finished and 48% of participants reporting % reduction in pain. As all the cases used in this trial filled the ICH criteria for TTH it demonstrated that there can be positive long term effects of specialised physiotherapy on headaches other than cervicogenic. If tension-type headaches are to be considered as part of the spectrum of primary headaches this also leads to the possibility of physiotherapy affecting migraines (Peres et al., 2007). 2. Sometimes the possible potential of physical therapies are demonstrated when the usual medication has to be stopped for some reason. One such paper described the treatment of a pregnant lady with long standing migraine (Alcantara and Cossette, 2009). This patient had suffered recurring migraine since age 12yrs and was advised not to take medication whilst pregnant. Some women experience a diminution of migraines whilst pregnant but this patient was getting worse so sought chiropractic help which relieved her chronic recurring migraine and lasted after the birth. This was only a single case study but, it is an example of long term beneficial results from treatment of the cervical spine which would not have been routinely recommended. One of the challenges of running a trial to assess the effects of a therapy is measuring and recording the actual treatment as good physical therapy constantly adjusts to the patients reactions which is an aspect of reflection in action (Schon, 1987). One way to address this is to measure the consistency of assessment by similarly trained therapists so that the basis from which the therapist works can be compared before the start of the trial. Good consistency was demonstrated on testing the similarities of assessments of cervical problems by trained physiotherapists (Jull et al., 1997). This shows that consistency of assessment can be achieved in controlled conditions by people of the similar training but it cannot be assumed that therapists with varied training and experiences would give these results. Examples of studies done by different professionals approaching a subject differently can be seen in two trials to find the prevalence of CVH in people with Primary Headaches. They were both aiming to find the prevalence of CVH using the ICH criteria. The one carried out by neurologists found the prevalence of cervicogenic headaches to be 4.1% (Sjaastad and Bakketeig, 2008).The other carried out by chiropractors gave a result of 18% (Nilsson, 1995). Page 5 of 9

6 Other modalities used in physiotherapy have been demonstrated as effective such as acupuncture (Vickers et al., 2004) where a randomized controlled trial and economic analysis was done to demonstrate the possible benefits of acupuncture for treatment of chronic headache disorders in primary care. As acupuncture is rarely used in isolation in physiotherapy treatments it could be speculated that the success measures would have increased if the acupuncture had been just one of the options in a whole treatment plan. Jenny Longbottom stresses the importance of clinical reasoning for the effective integration of acupuncture into manual or exercise therapy (Longbottom, 2011). Dean Watson who founded the International Headache institute ( works from the model of most primary headaches being, to some extent, affected by the cervical spine via the TCN (Bogduk, 2001). If the familiar headache pattern can be reproduced on examination at the first assessment he is confident of resolution of the headache by mobilisation of that joint. In an on 23 rd November 2010 D. Watson stated that his success rates to be in the order of 75% as currently being assessed by another PHD student in Australia (personal communication). His PhD is nearing completion and papers are in press. A 3 year trial to measure how well his techniques can be transferred to other physiotherapists is currently being run by Dr. Ian Davidson at the University of Manchester (Hunt, 2009). Sinus pains caused by infections are found to be far less common than generally assumed (Jones, 2009) and can usually be treated as another form of headache. Jones explains that the trigeminal nerve (the sensory nerve covering the head) has branches which cover the sinuses so the pain and mucus formation in the sinus area usually originates from agitation of this sensory nerve and not necessarily a sinus pathology. 5. Discussion The numerous classifications of primary headaches can be very confusing for the primary care physicians especially when some patients have symptoms from more than one category (Peres et al., 2007). It was these sorts of observations in a clinical setting which inspired Roger K. Cady to find evidence for his ideas that all his migraine and tension-type headache patients were on the same spectrum of disorders as part of the same pathophysiological mechanism. His evidence demonstrated that the various symptoms can be explained by over activity of the TCN in the brain. He named this The Convergence Hypothesis and conjectured that the Hypothesis might lead to broader directions in the future (Cady, 2007). This is a logical model for physiotherapists treating headaches to work from because of the direct connections of the upper cervical vertebrae and the TCN. Bogduk examined these structures carefully and described the the physiologic basis for this pain as being the convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves. The possible sources of cervicogenic headache lie in the structures innervated Page 6 of 9

7 by the C1 to C3 spinal nerves, and include the upper cervical synovial joints, the upper cervical muscles, the C2-3 disc, the vertebral and internal carotid arteries, and the dura mater of the upper spinal cord and posterior cranial fossa. Experiments in normal volunteers have established that the cervical muscles and joints can be sources of headache (Bogduk, 2001) This could explain how different factors such as hormonal and irritation from the cervical afferent nerves can, together, escalate into various types of headaches (Gonclaves et al., 2010). Previously the medical model of pain in migraine has been considered to be from dilating or expanding cranial arteries. This theory is not supported by research into the timing and consistency of blood flow alterations in the development of migraine type pain (Thomsen et al., 1995). These researchers reason that the alteration in blood flow could be considered more of a result rather than a cause of head pain. This altered blood flow being as a result of over active nerves would be dictated by TCN activity so would also support the Convergence Hypothesis. At present medication is incorrectly overused to such an extent that medication has become the most common cause of daily headache (Andrasik et al., 2007) so any approach to reduce this type of headache would be an area to be encouraged. There is very little evidence of physical treatments by trained professionals having adverse side effects. A survey of physiotherapists in Australia of over 100 cases found manipulations, mobilisations and exercises were chosen as appropriate and no serious adverse effects noted (Jull, 2002). 6. Conclusions This literature review has indicated: i) A lack of research on physiotherapy for headache treatments. ii) Difficulty in organising good trials of the effectiveness of physiotherapy. iii) There are different hypotheses on the aetiology of headaches. iv) Medication can have negative side effects. v) It has been shown that physiotherapy can have beneficial effects on primary headaches. 7. Recommendations 1. A pragmatic approach to the management of headaches would be to: a) Build on the best practice achieved by physical therapies b) Appropriate medication used alongside physical treatments 2. The Convergence Hypothesis would be a useful model to work from as it can encompass the rationale behind the causes and treatments of all Primary Headaches. Page 7 of 9

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