Let’s take the tension headache for example, a common condition. There is some debate as to whether this type of headache is curable, or whether the best we can do is help sufferers manage their symptoms.
From my experience the extent to which a patient can manage stress, lifestyle factors and posture has much to do with how successful we are in in treatment as these are all known to drive tension headaches.
Firstly I want to explain here the three most common types of headaches. The cervicogenic (neck related), migraine and tension type headache.
According to Ken Niere, specialist musculoskeletal physiotherapist and senior lecturer at La Trobe University, Melbourne, Australia, the cervicogenic headache accounts for up to a third of all headaches we are likely to see in clinical practice. The types of headaches are typically one sided, creep up from the neck and are felt as far as the temples and even around the eyes. The quality of the pain is usually dull and aching and may come and go throughout the day or be fairly persistent.
So how do we know if this type of headache is arising from a problem with your neck? We have good research evidence to show that if you have restricted neck movement in certain directions, are tender to palpate (feel) with altered range of movement about the joints of the upper neck and show weakens off the deep upper neck postural muscles - it is very likely that the headache is neck related.
Why is this important?
Well if we can identify specific findings on physical assessment, we can then set about using physiotherapy techniques to correct these. Further research by Dr Gwen Jull and her team at the University of Queensland in 2001, showed that specific manual (hands on) therapy applied to the neck combined with re-training of the deep upper neck muscles which support the head on neck, is associated with a significant reduction in headaches. From my own clinical experience, I have found this approach to be very effective and have relieved many patients of this type of headache.
This type of headache is referred to as a primary headache, in that the cause is more medical in nature. A migraine is considered to be partly due to auto-regulatory disturbances which result in dilation of the blood vessels deep inside the brain (the trigeminal vascular system). As a result, these usually one sided headaches can give a dull pulsing type of pain. Migraines are also commonly associated with a sensitivity to light and sounds which is why a dark room is preferred during an attack. There may also be a characteristic aura. These headaches are generally not considered curable, but can be managed well with certain types of drugs.
There is new evidence to suggest that medical acupuncture can be used to help abort an attack and also prevent the recurrence of migraines (prophylaxis) and as such its use is recommended in the most update medical (NICE) guidelines in the UK as an alternative to drug therapy when appropriate
What should also be considered is that many migraine sufferers also present with some degree of neck pain and stiffness which may benefit from physiotherapy treatment. Although this may not cure the migraine, it may also go some way towards helping to prevent attacks. As myofascial trigger points in the neck muscles are thought to help trigger migraines, these should be treated as part of physiotherapy treatment.
It must be remembered that migraines are associated with other triggers such as food types (in particular foods which contain amines, salicylate or glutamate chemicals) alcohol, allergies and stress. Stress is a big issue for many of us and one that needs to be addressed as part of any migraine management plan.
These are also in the group of primary headaches as they are due to a medical problem known as central sensitization. This occurs when the nervous system becomes very over active and sensitised with associated increases in muscle tension. The muscle tension is often across the shoulders and up the neck and exquisite tender points known as trigger points are often found within the muscles. The headaches which develop along with the muscle tension tend to be on boths sides of the head and can feel like a constant heavy pressure.
We also need to consider that hormonal fluctuations can affect sufferers of tension type headache, as well as migraine and cervicogenic headache to some extent. Some women for example may experience increased pain and sensitivity just before the menstrual cycle when oestrogen, serotonin and beta endorphin levels drop. Those going through or following the menopause may also be more generally pain sensitised and notice and improvement following and HRT implant or change of hormone replacement medication. Pregnant women in the first trimester are also prone to developing headaches as well as during the early post-natal phase. A good assessment should be able to detect these patterns and if necessary, further medical evaluation should be arranged.
In terms of which treatment techniques are most effective, massage is what many people turn to for relief however the effects tend to be temporary. Along with migraine, there is also very compelling recent evidence to suggest that medical acupuncture can help reduce tension type headaches severity and frequency. I use acupuncture to good effect and complement this with specific therapeutic exercises and relaxation techniques. Certain types of drug therapy have also been shown to be effective and may be used in combination with physiotherapy which includes acupuncture.
Please remember that there are other types of headaches and causes of headaches. If you ever develop a headache that is very out of the ordinary, severe and unremitting, or following any type of trauma or blow to the head - please see your GP for an evaluation. It may also be necessary to include other healthcare professionals such as dieticians and pain management medical consultants in the management of a headache.
This article was inspired by a recent podcast I listened to by Physio Edge.
Any Physiotherapist who is interested in attending a medical acupuncture course focused on the treatment of tension type headache and migraine please see BMAS
by Simon Coghlan