Osteopathic Approach to
Headache
Gautam J. Desai, DO, FACOFP
Lauren J. Branham, OMSIV, OMM Fellow
KCU Homecoming CME
Disclaimers
 Neither of the presenters nor the table trainers have
any true or perceived conflict of interest nor financial
conflicts.
 This presentation is for educational purposes only and
we are not able to offer individual OMT to attendees.
HEADACHE
PRIMARY
•
•
•
•
•
Migraines
Cluster
Analgesic
Tension
Cervicogenic
SECONDARY
•
•
•
•
•
•
•
•
•
•
•
SAH
Meningitis
Abscess
Tumor
Temporal arteritis
Pseudotumor cerebri
Vertebral artery
dissection
AV malformation
Chiari malformation
Cerebral aneurysm
Trigeminal Neuralgia
Assessment of Headache
PRIMARY
• History and
Physical
NO
RED FLAGS
•
•
•
•
•
Fever
Focal neurological deficit
Progressive + N/V
New onset >50 yo
Sudden onset
YES
SECONDARY
• CT
• LP
• Biopsy
Analgesic
Rebound
Tension/
Cervicogenic
Cluster
Migraines
Analgesic
Rebound
• Path: Withdrawal
• Pt: on pain meds
• Tx: Meds/NSAIDS/
Acetaminophen
Tension/
Cervicogenic
Cluster
Migraines
Analgesic
Rebound
• Path: Withdrawal
• Pt: on pain meds
• Tx: Meds/NSAIDS/
Acetaminophen
- Withdrawal; so
avoid
• Dx: Clinical
Tension/
Cervicogenic
Cluster
Migraines
Analgesic
Rebound
• Path: Withdrawal
• Pt: on pain meds
• Tx: Meds/NSAIDS/
Acetominophen
- Withdrawal; so
avoid
• Dx: Clinical
Tension/
Cervicogenic
• Path: Muscular/
Structural
• Pt: B/L Viselike;
radiates to neck or
from neck to head
• Dx: Clinical
• Tx: NSAIDs/OMT/
Acetaminophen
Cluster
Migraines
Analgesic
Rebound
• Path: Withdrawal
• Pt: on pain meds
• Tx: Meds/NSAIDS/
Acetominophen
- Withdrawal; so
avoid
• Dx: Clinical
Tension/
Cervicogenic
• Path: Muscular/
Structural
• Pt: B/L Viselike;
radiates to neck or
from neck to head
• Dx: Clinical
• Tx: NSAIDs/OMT/
Acetaminophen
Cluster
•
•
•
•
•
Path: Vascular
Pt: Asx for months 
30+ attacks in 1-3 days;
Horner’s Syndrome;
ipsilateral lacrimation,
conjunctival
inflammation,
rhinorrhea, periorbital
pain
Dx: Clinical
Tx: 100% HIGH FLOW O2;
Ergots; PPx w/ CCBs
F/U with Brain Imaging
Migraines
Analgesic
Rebound
• Path: Withdrawal
• Pt: on pain meds
• Tx: Meds/NSAIDS/
Acetominophen
- Withdrawal; so
avoid
• Dx: Clinical
Tension/
Cervicogenic
• Path: Muscular/
Structural
• Pt: B/L Viselike;
radiates to neck or
from neck to head
• Dx: Clinical
• Tx: NSAIDs/OMT/
Acetaminophen
Cluster
•
•
•
•
•
Path: Vascular
•
Pt: Asx for months 
30+ attacks in 1-3 days; •
Horner’s Syndrome;
ipsilateral lacrimation,
conjunctival
inflammation,
•
rhinorrhea, periorbital •
pain
Dx: Clinical
Tx: 100% HIGH FLOW O2;
Ergots; PPx w/ CCBs
•
F/U with Brain Imaging? •
Migraines
Path: Vascular
(vasodilation)
Pt: Photo/phonophobia;
TRIGGER, +/- Aura; 3648hrs; aborts with sleep
but have “hangover”
Dx: Clinical
Tx: Avoid Triggers; mild +
early = NSAIDs; Modsevere = Ergots/triptans
(caution in CAD)
PPX: CCBs; BBs
F/U with Brain Imaging?
Typical Patient Presentation: Cervicogenic Headache (CHA)
• Unilateral head pain
• Moderate to severe, deep, non-throbbing and non-lancinating
• Does not shift from side to side
• Fluctuates in intensity – increased by certain movements of the head or
sustained positions
• Radiates from occipital to frontal regions
• +/- history of whiplash/head/neck injury prior to symptom onset
• May have restricted neck range of motion, ipsilateral neck, shoulder or arm
pain
• Varying duration with lack of response to medications usually helpful in
alleviating other types of headaches
Osteopathic Structural Exam
• C-Spine shows decreased AROM and PROM in all planes,
somewhat worse with right sidebending and rotation
• Cervical paravertebral and upper trapezius musculature
demonstrate increased tone with mild tenderness to palpation
• Tenderness, muscular tension, and fullness in the suboccipital
region (R > L)
• OA F RrSl, AA Rr, C2-3 E RlSl, deep palpation radiates pain to
area of right orbit
• T1-3 N RrSl, T4-5 E RlSl
In the neutral position (seated
or prone), place thumbs over
the TP’s of vertebrae being
evaluated
Left thumb posterior
Right thumb posterior
= Left Posterior TP (PTP)
= Right Posterior TP (PTP)
= Left rotation
= Right rotation
Check in flexion &
extension
Symmetry
restored in
flexion
Symmetry
restored in
extension
F RL S L
E RL S L
Check in flexion &
extension
Symmetry
NOT
restored in
flexion or
extension
N RL S R
Symmetry
restored in
flexion
Symmetry
restored in
extension
F RR S R
E RR SR
Symmetry
NOT
restored in
flexion or
extension
N RR S L
Adapted from OMT Review, 3rd Edition, Savarese, 2002.
Practice Time
 Check your partner’s T spine for dysfunction
Anatomy Review
 Cervical Spine has 7 vertebral segments:
 Atlas (C1) and Axis (C2) are atypical
 Atlas has no vertebral body (rotates around dens)
 Vertebral body of C2 extends superiorly to form dens
(odontoid process)
 Articulation between C2 and C3 and rest of cervical
joints is considered typical
 Facets are in a plane that points towards the eye in the
uppers, and opposite ASIS for the lower segments
 Important for manipulative force vectors
Biomechanics
Occipitoatlantal (OA) Joint:
 Major motions: flexion & extension
*Minor motions: SB & rotation
 The occiput rotates and SB to opposite sides
Biomechanics
Atlantoaxial (AA) joint:
 Primary motion: rotation
*atlas rotates about the dens
 Almost no SB or flexion/extension
Biomechanics
Typical Cervical Segments (C2 thru C7):
 Rotation and SB: same side
*but some find clinically, SB and rotation to opposite sides
 Modified Type II Mechanics
Structural Evaluation
Base off of patient’s H&P:
 Problem with:




jaw
cervical, thoracic or lumbar spine/innominates
patient’s spirit (depression, anxiety, stress)
work-related (hairdresser, manual labor)
Try to elucidate how structure is affecting function
Remember to check the first rib
 Often a culprit as a trigger for headaches
 Especially in pts who use hands/upper back at work
 Students carrying backpacks, etc.
Cervical Spine Treatment
OA
 Suboccipital Release
 Cup occiput and give gentle axial traction and some lateral
traction
 Wait for musculature to relax
 Teach pts to do at home with pillow
 AT Still did to himself
Cervical Spine Treatment
AA
 Muscle Energy
 Fully flex head and neck then rotate into the barrier
 Ask the pt to gently move head and neck to neutral while
dr resists motion
 Relax, move to next new barrier and then repeat process
until no new barriers reached
Muscle Energy Treatment
Typical Cervicals (i.e. C3ERRSBR)
 Muscle Energy
 Pt seated/supine with dr standing behind pt
 Dr’s R index finger on PTP (C3 in this case), and rest of
hand on side of neck, dr’s L hand atop pt’s head
 Take to barrier: in this case flex, SB and rotate L
 Pt to gently straighten head vs. dr’s resistance for 3-5
seconds
 During period of relaxation, take further into barrier (more
flexion, SB left, and rotation left)
 Repeat 3 times
Cervical Spine Treatment
Scalene muscles
 Myofascial release
 Pt seated
 Dr stands behind pt
 Grasp scalene muscle with thumb and index finger and pull
towards dr
 Perpendicular stretch
 Now SB head away from side you are stretching
 Longitudinal stretch
Practice Time
 On your partner:
 Check C spine
 Do suboccipital release
 AA and typical C spine ME
Cervical Spine Treatment
Typical Cervicals
 Still’s Technique (i.e. C3ERRSBR)
 Pt supine with dr at head of table
 Dr’s R index finger on PTP (C3 in this case), and rest of
hand wrapped around side of neck to support (and also to
use as a fulcrum)
 Dr’s L hand on top of pt’s head
 Take where dysfunction already is and exaggerate: in this
case extend, and SB and rotate R.
 as pt supine, extension and SB are minimal, but rotate until you
feel relaxation of tissues.
 this removes strain from affected segment
Cervical Spine Treatment
Typical Cervicals
 Still’s Technique (i.e. C3ERRSBR)
 Push down on head with L hand (axial compression)
 Move head away from area of dysfunction.
 Rotate head to L, while simultaneously SB L, and flexing cspine.
 Take to barrier, and as you are moving, may feel release with
monitoring hand at PTP.
 Release compression, and take pt back to neutral
 Retest
Upper Extremity Treatment
Rhomboid Stretch




Pt seated (or supine), with dr standing facing pt
Place finger pads on medial and inferior aspect of scapula
Drape pt’s arm over your forearm
Attempt to roll your fingers under medial edge of scapula to
apply traction to rhomboids
 Continue traction while exerting a lateral force against medial
aspect of scapula
 Relax and reapply traction force 3-5 times
Thoracic Treatment
Still’s Technique
 Pt seated (or supine) , dr standing on side of tx
 With one hand, contact tissues between rib angle and transverse
process and spring anteriorly to feel for hard endfeel
 With other hand, grab olecranon and induce motion in UE, so
olecranon moves toward contact point of posterior hand, until
motion felt at contact point
Thoracic Treatment
Still’s Technique (continued)
 Now ADduct UE at shoulder until motion felt at contact point.
 Determine if internal or external rotation at shoulder is freer
motion
 Depending on which motion is freer, continue arc of motion in
upper extremity 360 degrees.
 If internal rotation freer: arc of motion is as if using an
overhand throwing motion
 If external rotation freer: arc of motion is as if using an
underhand throwing motion
Thoracic Treatment
Still’s Technique (continued)
 Usually articulation or palpable motion felt at contact point of
posterior hand.
 Recheck segment by springing anteriorly.
 Repeat for each thoracic level
 Best to start at T-12 and work superiorly
 After 1 side of cage complete, repeat on other side
Practice Time
 Cervical Still’s
 Rhomboid Stretch
 Thoracic Still’s
Lumbar Spine
Always important to check from below in pts with
cephalgia
 May find adult onset scoliosis
 Asymmetrical lumbar spine may cause muscle tension
above due to desire to keep eyes level
S/P MVA
Check innominate lengths
 Usually asymmetrical in cephalgia pts
 Especially if hx hip fx, ankle injury
Check ASIS and medial malleoli b/l
The Best Treatment is Prevention!
 Search for triggers, and have your pts avoid them
 Do stretching exercises
 Reduce stress
 Need multifaceted approach for treatment success
Can OMT save money?
One study reviewed EMRs from 631 pts seen at 2 Florida residency clinics

One osteopathic and had OMT available, and the other allopathic and did not offer OMT

1427 office visits for migraine related reasons

Costs tallied



Average cost per pt visit was approximately 50% less at osteopathic clinic than at allopathic clinic ($195.63 vs
$363.84, respectively; P<.001).
Entirely attributable to difference in average # of meds rx’d per visit at the two clinics
 0.696 prescriptions at the osteopathic clinic and 1.285 prescriptions at allopathic clinic (P<.001)
 Lower average med cost per visit at osteopathic clinic than at allopathic clinic ($106.94 vs $284.93, respectively;
P<.001).
 Pts at the osteopathic clinic 5 years younger on average than allopathic clinic (P<.001)
 No statistically significant difference observed btw two practices in pts' ratings of pain severity
Authors’ Conclusion: The inclusion of OMT in a treatment regimen for patients with migraine
headache may lower the cost of the treatment regimen. However, further study is needed to
confirm these results.
Schabert, Crow, Impact of OMT on Cost of Care for Patients With Migraine Headache: A Retrospective Review of Patient Records , JAOA August 1, 2009 vol.
109 no. 8 403-407
Bibliography
1. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria.
Headache. 1990;30(11):725.
2. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A
randomized controlled trial of exercise and manipulative therapy for cervicogenic
headache. Spine (Phila Pa 1976). 2002;27(17):1835.
3. Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. J Orthop Sports Phys Ther.
Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of
cervicogenic headache. 2007 Mar;37(3):100-7.
4. Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J 2001;1(1):3146
5. Pollmann W, Keidel M. Headache and the cervical spine: a critical review. Cephalgia
1997;17:801-816
6. Schwartz BS, Stewart WF. Lost workdays and decreased work effectiveness associated with
headache in the workplace. J Occup Environ Med 1997;39(4):320-327
7. Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther.
1992;15(1):6
8. Hruby, Raymond J. Ch. 60 Cervicogenic Headache. Foundations of Osteopathic Medicine,
3rd ed.
9. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Third occipital nerve headache: a prevalence
study. J Neurol Neurosurg Psychiatry. 1994;57(10):1187
10. Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J
Am Osteopath Assoc. 2000;100(9)
Bibliography (continued)
11. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical
diagnosis, invasive tests, and treatment. Lancet Neurol. 2009;8(10):959.
12. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med.
2007;8(4):344.
13. Foreman RD. Integration of viscerosomatic sensory input at the spinal level. Prog Brain
Res 2000;122:209-221
14. Bogduk, N. Distinguishing primary headache disorders from cervicogenic headache:
clinical and therapeutic implications. Headache Currents. 2005; 2:27.
15. The International Classification of Headache Disorders, 3rd edition (beta version).
Headache Classification Committee of the International Headache Society (IHS).
Cephalalgia. 2013 Jul;33(9):629-808.
16. Bogduk N. The neck and headaches. Neurol Clin. 2004;22(1):151.
17. Joshua D. Brooks, PhD on AMA Wire 12/8/2014
18. COILS – Patient with a headache, AACOM’s Education Council on Osteopathic
Principles. 2015.
19. Cervicogenic headache after whiplash injury. Drottning M, Staff PH. Cephalalgia
2002;22(3):165-171.
20. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: A documentation
of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193–210.
21. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost
due to common pain conditions in the US workforce. JAMA. 2003,290(18):2443-2454.