6/11/21
Headaches
Carol A. Courtney PT, PhD
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Objectives
Introduce you to the The International Classification of Headache
Disorders website (a great resource!)
Describe characteristics of some of the common headaches seen by PTs
Discuss examination techniques for headache patients
Discuss common interventions for the headache patient
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Carol A Courtney
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6/11/21
Headache
Global Burden of Disease Study 2010, tension-type headache
(TTH) and migraine are, respectively, the second and the
third most common diseases in the world, after dental caries
Vos 2012
Mean 1-year prevalence (all headaches): 46% Stovner 2007
National and international guidelines focus primarily on
pharmacological management
Bendtsen 2010, Pryse-Phillips 1998
Increasing evidence for non-pharmacological management
Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010:
A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163-2196.
Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: A documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193-210
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Headache Classification
https://ichd-3.org/
Classified into 3 main categories:
Part I: The primary headaches
• Structure in the head is the source of pain; ie, primary disorder
Part II: The secondary headaches
• Structure outside of the head is the source of pain
•Is due to another diagnosis
Part III: Neuropathies & Facial Pains and other headaches
• Neuropathic source of symptoms
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Carol A Courtney
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6/11/21
Headache
Three of the more common forms seen by physical
therapists:
◦ migraine
◦ tension type
◦ cervicogenic headache
associated with a high burden of suffering and considerable
socioeconomic costs
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Central Sensitization (Central Nociplasticity)
occurs following repetitive or intense
noxious stimulus Latremoliere and Woolf 2009
Characterized by:
— Increased excitability of nociceptive
pathways
— Impaired descending inhibition
Central
Sensitization
Peripheral
Peripheral
Sensitization
Sensitizer
Inflammatory mediators
Adapted from Costigan 2009
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Carol A Courtney
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Peripheral Driver of
Central Sensitization
Nociceptive Input from:
Cerviogenic Headache
Upper Cx Articular Structures
Haldeman and Dagenais 2001
Tension Type Headache
Myofacial Tissues
Fumal and Schoenen 2008
Migraine
Meningeal & other cerebral blood vessels/sinuses
Noseda and Burnstein 2013
Haldeman and Dagenais 2001
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Poll Question #1
YOUR PATIENT HAS TESTED POSITIVE FOR THE COVID VIRUS
AND PRESENTS WITH A SEVERE HEADACHE. USE THE ICHD3
SITE TO DETERMINE A DIAGNOSIS FOR YOUR PATIENT. WHICH
OF THE FOLLOWING IS A POSSIBLE DIAGNOSIS OF HIS
HEADACHE?
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Carol A Courtney
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Differential
Diagnosis of
Headaches
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Examination of the patient
with headaches
Even Migraine patients require thorough PT exam because:
• Very common to have 2 or more headaches in same patient
• With Central Nociplasticity, musculoskeletal impairments can
drive central sensitivity
• May identify psychosocial drivers of the condition; make
appropriate referral
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Carol A Courtney
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Subjective screening
Reminder:
Duration of headaches
Components of the Subj. Exam
Frequency to headaches
A. Pain Diagram
Do they have an aura?
B. Behavior of Sx
C. Screening
D. History
Intensity of headaches
Effect of sustained postures?
Unilateral? Side shift?
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Migraine
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Types of Migraine (https://ichd-3.org/1-migraine/)
1.1 Migraine without aura
1.2 Migraine with aura
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Migraine with Aura
Aura with similar features also described in association
with other headaches, including Cluster Headache
Aura: a series of sensory disturbances that happen
shortly before a migraine attack
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Aura
Visual aura is common but may also be sensory loss, weakness,
dysphasia
Examples:
Phosphenes:
◦ eg, sparks, flashes, geometric forms
Scotoma:
◦ area of diminished vision moving across visual field
Scintillating scotoma:
◦ flickering spectrum at margin of scotoma
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Aura
Transient cortical event = cortical spreading depression
Slowly propagating wave of neuronal/glial depolarization followed by
prolonged inhibition
Local release of ATP, glutamate, K+ ions, H+ ions, CGRP and nitric oxide
Noseda and Burnstein 2013
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Carol A Courtney
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Sensitization of meningeal nociceptors mediates
throbbing nature of migraine pain
= Peripheral
Sensitization
Sensitization of 2ᵒ neurons in spinal trigeminal nucleus caudalis (SpVC)
mediates cephalic allodynia and muscle tenderness
= Central
Sensitization
Noseda and Burnstein 2013
Cutaneous allodynia is marker of central nociplasticity &
independent predictor for migraine chronification
Cuadrado 2008, Louter 2013
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1.1 Migraine without Aura
Diagnostic criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following characteristics:
◦ unilateral location
◦ pulsating quality
◦ moderate or severe pain intensity
◦ aggravation by or causing avoidance of routine physical activity (eg, walking or
climbing stairs)
D. During headache at least one of the following:
◦ nausea and/or vomiting
◦ photophobia and phonophobia
E. Not attributed to another disorder
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Carol A Courtney
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Management
Avoid dietary triggers (caffeine, artificial sweeteners, and additives such
as monosodium glutamate)
Behavioral Therapy (relaxation, Cognitive Behavioral Therapy, stress
reduction)
Medications
McGregor Ann Intern Med 2017
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McGregor
Ann Intern Med
2017
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Medications for Migraines
Triptans: drug of choice
effective in relieving the pain, nausea, and sensitivity to light and
sound
Example: sumatriptan (Imitrex)
Side effects: nausea, dizziness and muscle weakness
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Medications for Migraine
Ergot
Ergotamine and caffeine combination drugs (Migergot,
Cafergot)
• much less expensive, but also less effective, than triptans
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Carol A Courtney
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Preventative Medications for Migraine
Beta blockers
Anti-depressants
Anti-seizure drugs: valproate (Depacon), topiramate
(Topamax) and gabapentin (Neurontin) seem to reduce the
frequency of migraines
Lamotrigine (Lamictal) may be helpful if you have migraines
with aura
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3.1. Cluster Headaches
https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/
Attacks of severe, strictly unilateral pain
is orbital, supraorbital, temporal or a combination of
these sites
lasts 15-180 min and occurs from once every other
day to 8X/day
attacks are associated with ≥ 1 of (all are ipsilateral):
◦ conjunctival injection
◦ lacrimation
◦ nasal congestion
◦ rhinorrhoea
◦ forehead and facial sweating
◦ miosis, ptosis, eyelid edema
◦ Most patients are restless or agitated during an attack
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Carol A Courtney
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Cluster Headaches
During the worst attacks, the intensity of pain is excruciating
Patients unable to lie down; characteristically pace the floor
Age at onset: 20-40 years
Prevalence: 3-4 times higher in men than in women
ICHD3 classifies it as a 3. Trigeminal autonomic cephalalgias (TACs)
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Cluster Headache
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by at least one of the following:
◦ ipsilateral conjunctival injection and/or lacrimation
◦ ipsilateral nasal congestion and/or rhinorrhoea
◦ ipsilateral eyelid oedema
◦ ipsilateral forehead and facial sweating
◦ ipsilateral miosis and/or ptosis
◦ a sense of restlessness or agitation
D. Attacks have a frequency from one every other day to 8 per day
E. Not attributed to another disorder
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Carol A Courtney
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Medical Management
Acute treatment:
Sumatriptan subcutaneous, Zolmitriptan nasal spray, and high flow
oxygen - Level A recommendation
Sphenopalatine ganglion stimulation - Level B recommendation
Prophylactic therapy:
Suboccipital steroid injections - Level A recommendation
Robbins 2016 Headache
American Headache Society Guidelines
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Poll Question # 2
WHICH ASSESSMENTS DO YOU THINK WOULD BE
IMPORTANT TO INCLUDE IN YOUR EXAMINATION FOR
A PATIENT THAT YOU HYPOTHESIZE MAY HAVE
MIGRAINE OR CLUSTER HEADACHE?
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Carol A Courtney
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2. Tension Type Headache
Most common type of H/A
Overarching syndrome of ‘featureless’ headaches characterized by nothing but pain
in the head
Lifetime prevalence in the general population ranging in different studies between
30% and 78%
ICHD 3
Overlap between TTH and Migraine (without aura)
Also overlap with fibromyalgia
Fernandez de las Penas 2009
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Tension Type Headache
https://ichd-3.org/2-tension-type-headache/
Diagnostic criteria:
Headache lasting from 30 minutes to 7 days
Headache has at least two of the following characteristics:
◦ bilateral location
◦ pressing/tightening (non-pulsating) quality
◦ mild or moderate intensity
◦ not aggravated by routine physical activity such as walking or climbing stairs
Both of the following:
◦ no nausea or vomiting (anorexia may occur)
◦ no more than one of photophobia or phonophobia
Not attributed to another disorder
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Carol A Courtney
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Mechanisms
Central sensitization (nociplasticity) a component of TTH
De Tommaso 2003
Both peripheral and central sensitization mechanisms evident
• repetitive peripheral noxious input causes central nociplasticity
What then is the peripheral input?
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Pericranial
Tenderness:
1. Trigger Points
2. Muscle tenderness
Fernandez de las Penas 2009
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Carol A Courtney
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Why trigger points? Why muscle pain
referred to the head?
Myofascial afferents from several different areas converge on the same 2nd order neurons;
spread of pain mechanism: Heterosynaptic Facilitation (see notes from NS lecture)
= diffuse, poorly localized pain
•Referred pain is central nociplasticity (due to secondary hyperalgesia)
• Active Trigger Points: produce *pain
• Latent Trigger Points: evoke unfamiliar pain
Definition: presence of taut band; evokes referred pain on palpation
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Differentiated by frequency
and pericranial tenderness
2.1 Infrequent episodic tension-type headache
◦ 2.1.1 Infrequent episodic tension-type headache associated with pericranial tenderness
◦ 2.1.2 Infrequent episodic tension-type headache not associated with pericranial tenderness
2.2 Frequent episodic tension-type headache
◦ 2.2.1 Frequent episodic tension-type headache associated with pericranial tenderness
◦ 2.2.2 Frequent episodic tension-type headache not associated with pericranial tenderness
2.3 Chronic tension-type headache
◦ 2.3.1 Chronic tension-type headache associated with pericranial tenderness
◦ 2.3.2 Chronic tension-type headache not associated with pericranial tenderness
2.4 Probable tension-type headache
◦ 2.4.1 Probable infrequent episodic tension-type headache
◦ 2.4.2 Probable frequent episodic tension-type headache
◦ 2.4.3 Probable chronic tension-type headache
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Carol A Courtney
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Differences in TTHs
Frequency:
Infrequent episodic: At least 10 episodes occurring on <1 day per month on
average (<12 days per year)
Frequent episodic: At least 10 episodes occurring on ≥1 but <15 days per
month for at least 3 months (≥12 and <180 days per year)
Chronic: Headache occurring on ≥15 days per month on average for >3 months
(≥180 days per year). Headache lasts hours or may be continuous
Probable: missing one of the features required to fulfil all criteria for a type or
subtype of TTH
Pericranial Tenderness: muscle palpation
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Total Tenderness Score
4 Muscles (bilateral)
SCM, Upper Trap, Erector Spinae (C2-7), Suboccipitals
0 = no visible reaction and denial of tenderness;
1 = no visible reaction but verbal report of discomfort or mild
pain on questioning;
2 = spontaneous verbal report of painful tenderness before
questioning, possibly with facial expression of discomfort;
3 = marked grimacing and withdrawal, verbal report of marked
painful tenderness and pain
Bendtsen 1995
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Carol A Courtney
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11.7 Temporomandibular Dysfunction
https://ichd-3.org/11-headache-or-facial-pain-attributed-to-disorder-of-the-cranium-neck-eyes-ears-nose-sinuses-teeth-mouth-or-other-facial-or-cervical-structure/11-7-headache-attributed-to-temporomandibular-disorder-tmd/
Diagnostic Criteria
Clinical evidence of painful pathological process affecting temporomandibular
joint(s), muscles of mastication and/or assoc. structures on one or both sides
Evidence of causation demonstrated by ≥ two of the following:
◦ headache has developed in temporal relation to the onset of temporomandibular
disorder, or led to its discovery
◦ headache is aggravated by jaw motion, jaw function (eg, chewing) and/or jaw
parafunction (eg, bruxism)
◦ the headache is provoked on physical examination by temporalis muscle palpation
and/or passive movement of the jaw
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Relationship between TMD and H/A
Studies suggest relationship between Upper Cx impairments &/or
cervicogenic headache AND temporomandibular dysfunction
Grondin 2015, von Piekartz 2016, Greenbaum 2017
Key point:
1. If TMD is suspected, assess Cx spine
2. If upper Cx spine dx or headache, assess TMJ
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Carol A Courtney
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Poll Question # 3
YOUR PATIENT HAS A 6 MONTH HISTORY OF A DULL
HEADACHE, 4/10 PAIN, THAT LASTS 1-5 DAYS WHEN THEY
OCCUR. SHE STATES SHE HAS THEM TWICE/MONTH AND
WHEN PRESENT SHE NOTES TENDERNESS OF HER HEAD AND
NECK MUSCLES. WHAT IS HER DIAGNOSIS?
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11.2.1 Cervicogenic Headache
https://ichd-3.org/11-headache-or-facial-pain-attributed-to-disorder-of-the-cranium-neck-eyes-ears-nose-sinuses-teeth-mouth-or-other-facial-or-cervical-structure/11-2-headache-attributed-to-disorder-of-the-neck/11-2-1-cervicogenic-headache/
Description:
Headache caused by cervical spine disorder and its component bony, disc and/or soft
tissue elements, usually accompanied by neck pain
Prevalence: 1-4.1%; 53% post whiplash
Bogduk and Govind 2009
Diagnostic criteria:
B. Clinical and/or imaging evidence1 of a disorder or lesion within the cervical spine or
soft tissues of the neck, known to be able to cause headache2
C. Evidence of causation demonstrated by at least two of the following:
◦ headache has developed in temporal relation to the onset of the cervical disorder or
appearance of the lesion
◦ headache has significantly improved or resolved in parallel with improvement in or
resolution of the cervical disorder or lesion
◦ cervical range of motion is reduced and headache is made significantly worse by
provocative maneuvers
◦ headache is abolished following diagnostic blockade of a cervical structure or its nerve
supply
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Carol A Courtney
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Cervicogenic Headache
Dwyer, April, Bogduk 1990
Referred pain by stimulating
the facet (healthy subjects)
Bogduk and Marshland 1988
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Exam for the
Headache Patient
SEE HEADACHE EXAM ALGORITHM AS A REFERENCE
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Carol A Courtney
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Subjective Exam
Pain Diagram
Behavior (Aggr, Ease, 24 hr, etc)
Screening (Meds, PMH, image, etc)
History (present, past, work, prev. PT etc)
Duration of headaches
ALSO:
Frequency to headaches
Sinus issues?
Do they have an aura?
Eye strain? Glasses/contacts?
Intensity of headaches
Dietary triggers?
Effect of sustained postures?
Psychosocial screening (related to headache?)
Unilateral? Side shift?
Also - important screening:
History of trauma? MVA? RA? Downs Syndrome? Connective
tissue dx?
•These are triggers to examine for Upper Cervical instability
Screen for 6.5 Cervical Arterial Dysfunction
•Involves both subjective and physical screen -
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Upper Cervical Instability: Examination
If high suspicion of upper cervical instability - refer for imaging (open mouth,
lateral view in flexion/extension, AP, MRI may be indicated if neuro deficits
present)
Mintken 2008
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Lab
Alar Ligaments
◦ L and R alar ligaments
pass from dens to
occipital condyles
(connect C0 to C2),
primarily resist axial
rotation and lateral
Neumann DA. Kinesiology of the musculoskeletal system - foundations for rehabilitation. 3rd ed. Elsevier Health
flexion
Sciences; 2017.
Alar Ligament Stress Testing
◦ Patient position: supine
◦ Therapist stabilizes spinous process of the C2,
then laterally flexes C0 and C1
◦ Positive test: excessive motion, empty end feel
◦ Test repeated with rotation of C0 and C1
Mintken PE, Metrick L, Flynn TW. Upper cervical ligament testing in a patient with os odontoideum presenting with
headaches. The Journal of orthopaedic and sports physical therapy. 2008;38(8):465-475.
http://www.ncbi.nlm.nih.gov/pubmed/18678962. doi: 10.2519/jospt.2008.2747.
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Lab
Transverse Ligament
◦ Holds dens to C1, resists
anterior translation of
dens during flexion
(prevents dens from
bumping up to spinal cord)
Neumann DA. Kinesiology of the musculoskeletal system - foundations for rehabilitation. 3rd ed. Elsevier Health
Sciences; 2017.
Transverse Ligament Testing - Anterior Shear Test
◦ Patient position: supine, head in neutral on pillow
◦ Therapist cradles occiput with 3rd-5th fingers,
index fingers placed in space between occiput
and C2 spinous process. Head and C1
lifted/sheared anteriorly together (head
maintained in neutral, gravity stabilizes lower Cspine)
◦ Positive test: sensation of lump in the throat,
presence of cardinal signs/symptoms (i.e.
paresthesias)
Mintken PE, Metrick L, Flynn TW. Upper cervical ligament testing in a patient with os odontoideum presenting with headaches.
The Journal of orthopaedic and sports physical therapy. 2008;38(8):465-475.
http://www.ncbi.nlm.nih.gov/pubmed/18678962. doi: 10.2519/jospt.2008.2747.
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Carol A Courtney
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Lab
Transverse Ligament
◦ Holds dens to C1, resists
anterior translation of
dens during flexion
(prevents dens from
bumping up to spinal cord)
Neumann DA. Kinesiology of the musculoskeletal system - foundations for rehabilitation. 3rd ed. Elsevier Health
Sciences; 2017.
Transverse Ligament Testing - Sharp-Purser Test
◦ Patient position: sitting
◦ Therapist places one hand on the forehead,
other hand stabilizes spinous process of C2 via
pinch grip. Patient’s head is gently flexed, then
pressure applied through the forehead to
posteriorly translate occiput and C1
◦ Positive test: possible provocation of cardinal
signs/symptoms with flexion with relief upon
posterior translation. Sliding or clunking during
reduction may also be positive
Mintken PE, Metrick L, Flynn TW. Upper cervical ligament testing in a patient with os odontoideum
presenting with headaches. The Journal of orthopaedic and sports physical therapy. 2008;38(8):465475. http://www.ncbi.nlm.nih.gov/pubmed/18678962. doi: 10.2519/jospt.2008.2747.
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Cervical Arterial Dysfunction (CAD)
◦ Anatomical and pathological
spectrum of events that may
occur in the arterial structures of
the cervical region.
◦ Includes temporary mechanical
occlusion, dissections, or
thromboembolic events.
◦ Involves the anterior (internal
carotid) and/or posterior
(vertebrobasilar) arterial
systems.
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Pain presentation with CAD
Taylor & Kerry 2010 Int J Osteopath Med
Thomas 2015 JOSPT
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Subjective Examination - CAD
•
Other screening questions:
o (5 D’s) Dizziness, diplopia, dysarthria,
dysphagia, drop attacks
o Tinnitus
o
o
o
o
o
Nausea/vomiting
Headache
Difficulty with balance/falls
Limb weakness
Numbness/tingling (UE/LE/other areas?)
•
Past Medical/Social History:
o
o
o
o
o
Cardiovascular disease*
Neurological disease
Inflammatory arthritis
Smoking
Family History
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Physical Exam - CAD
•Sustained end-range rotation has been
advocated and described as the most
provocative and reliable test Mitchell 2004
•Diagnostic accuracy data calls into
question utility of these tests Hutting 2012
•Sustained pre-manipulative test position
(i.e. placing head and neck in position of
the selected manipulative technique) has
also been advocated
Rivett 2006
•predictive ability of either of these tests to
identify at risk individuals is lacking
Perform
Bilaterally –
Sustain 10 s.
Assess for sx
of nystagmus,
nausea, dizziness
Pre-manipulative hold
Sustain 10 s.
Assess for sx
of nystagmus,
nausea, dizziness
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Screen TMJ
• Mouth Opening and closing
• This can be a brief screen
• If findings, you may add OP,
assessment of other active
movements and/or passive
movements
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Physical Exam
• Postural Deficits (forward head
posture, Cx-Tx kyphosis, etc)
•Symptom Provoking Functional
Activity (looking down at laptop; at a screen, Rot backing car)
• AROM Cx Spine + Upper Cx spine: may
find pain and limitation upper Cx
flex/ext; limited Rotation
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Active ROM Cervical Spine
Standard Cervical Spine AROM (always performed) + OP
1. Flexion “chin to chest”
2. Extension “Look up to the ceiling”
3. Lateral Flexion: “Tip your ear to your shoulder”
4. Rotation: “Turn your head to the left/right”
Now, your clinical reasoning directs decision to add other movements
Headache patient? add:
1. Upper cervical flexion: “Tuck chin in”
2. Upper cervical extension: “Poke chin forward”
Patient has apparent cervicothoracic impairment? Add:
1. Lower cervical extension: “Tuck your chin, then tilt your head back”
You’ve not really found a comparable (*) sign? Add:
Combined Movements
Sustained, repeated, fast, etc
Compression/Distraction
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General Cervical Extension
“Look up to the ceiling”
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General Cervical Flexion
“chin to chest”
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Lateral Flexion
“Tip your ear to your shoulder”
FIRST:
Have the patient perform to both
directions to compare movement to
each side; then overpressure
Fulcrum
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Rotation
“Turn your head to the
left/right”
FIRST:
Have the patient perform to
both directions to compare
movement to each side; then
overpressure
Notice the
elbow blocking
Thoracic spine
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Carol A Courtney
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Clinical
Reasoning
decision..
AF TER YO U EXAMINE STRAIGHT
PL ANE ARO M, SU B JEC TIV E F INDINGS
W ILL DI C TATE THE ADDITIO N O F
OTH ER ARO M MOV EMENTS
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Upper Cervical Flexion
“Tuck your chin in”
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Upper Cervical Extension
“Poke chin forwards”
Rotate head back on neck
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Lower Cervical Extension
“Tuck your chin, then tilt your
head back”
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Combined Movement: Extension,
Lat Flex, Rot Toward
Patient actively moves into lower
cervical extension,
Place your thenar eminence under
zygamatic arch
Add lateral rotation
Add rotation
Keep the first component;
+/- the second/third components
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Compression and distraction
Compression: be gentle; may
increase symptoms; implicates
joint as source of pain?
Distraction: lift off the weight of
the head; may relieve resting
symptoms
(if you pull too hard you will
stretch joint tissues = pain)
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Carol A Courtney
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Physical Exam - continued
•Palpation: Tenderness in upper
cervical region (see video)
• PROM: (see video)
◦ Hypomobility with Passive Physiological
intervertebral movement (PPIVMS)
◦ Hypomobility with Passive Accessory
intervertebral movement (PAIVMS)
◦ Total tenderness score
◦ Cranial nerve assessment; if appropriate,
QST, neurological exam
◦ Measure proprioception (Joint Position
Error)
◦ Pain and possible reproduction of HA with PROM
• Flexion Rotation Test (see video)
• Headache Disability Index (outcome
measure)
Craig will cover:
◦ Muscle Strength deficits in craniocervical
flexion endurance test
◦ Assessment scapular musculature
(strength and muscle length assessment)
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Cervical Flexion Rotation Test
In full Cervical Flexion
Assess amount rotation (L vs R)
Measure with Goniometer
“cut point for positive test is
range of rotation < 32°”
Ogince et al 2007
Hall & Robinson 2004
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Joint Position Error: a measure of
proprioception
Trealeaven 2007
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Joint Position Error Testing
Target is placed 90 cm in front of patient
Neutral resting position
Familiarize with movement (Rot; Flex/ext)
Blindfold
Perform 3 trials – take mean of absolute error
http://www.skillworks.biz/Resources/Documents/JPE%20Target%20and
%20Instructions.pdf
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Interventions
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Patient Education
Postural education
Advise to avoid sustained positions
Advise to take frequent breaks
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Neuromuscular Rehabilitation
Work on proprioception
◦ Joint Position Error
Restore proper muscle length and strength of spinal/scapular/trunk
musculature
◦ Craniocervical deep neck flexor muscle endurance training
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Manual Therapy
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Randomized Controlled Trials:
Cervicogenic H/A
Jull G 2002 Spine
◦
Subjects:
◦
Compared:
◦
◦
◦
200 fulfilled the IHS criteria for cervicogenic h/a
4 groups: manipulation, exercise, combined, control
Outcome measures:
◦
headache frequency, intensity and duration
MT and exercise both significantly better than control; MT + ex better than
each individually, but not significantly
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Interventions
PAIVMs at Upper Cx spine
◦
◦
◦
◦
Examples:
O-C1 unilateral PA
Longitudinal (sometimes called distraction)
PPIVMs at Upper Cx spine (for example at
C1-2 or C2-3)
Maitland text
Picture from Fernandez de las Penas 2006
Thrust
manipulation
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Intervention
Mobilization with Movement
SNAGs
◦ Sustained natural apophyseal glides
Hall 2007
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Treatment
Thoracic Thrust Manipulation
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What about
for muscle
TPs?
Pressure release, muscle energy or soft tissue techniques, were
applied to these muscles in order to inactivate active muscle TrPs
Exercise program based on deep flexor and extensor muscle lowload and progressive contractions
◦ Fernandez de las Penas 2008
**Recall that low load isometric exercise facilitates descending pain inhibition
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Dry needling
Minimally invasive procedure in which an acupuncture needle is inserted
directly into a trigger point
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Carol A Courtney
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6/11/21
Treatment
Aerobic/ cardiovascular exercise and
conditioning
Recall from MSK 2 lecture:
Recommend intensity >50% VO2max and
duration >10 min to elicit exercise
analgesia
Hoffman 2004
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Thank you!
80
Carol A Courtney
40