Headache Tree No Red Flags: Worst HA of life, wake up at night, altered/LOC Dizziness Laterality of Sx? Unilateral (or U on both sides) Bilateral (sx reproduced B at the same time) Tension HA Tx: Pharmacological Neck Motion, Valsalva, Pressure over C1-C3 Refer to MD/ER Refer to Vestibular Sheet Palpation: Sx may occur ipsilaterally or shift to contralateral side Palpation: sx occur ipsilaterally Multiple, but not neck motion Triggers? Multiple, but not neck motion Alcohol, Occurs at predictable times/day Cervicogenic HA Tx: PT (jt mobs/manips, stretching, STM, strengthening, postural/NM re-education, TENS, biofeedback) and/or Pharmacological Cluster HA Tx: Pharmacological Migraine HA Tx: Pharmacological None Hemicrania Continua HA Tx: Pharmacological Adapted from Biondi (2005) Differential Dx for Headaches Biondi (2005) Female : Male Ratio Laterality Location Duration Triggers Associated Symptoms Pharmocological Treatment Cervicogenic Migraine Cluster Hemicrania continua F>M Tension F>M F>M M>F Unilateral (no sideshift) Occipital to frontoparietal and orbital Intermittent or constant Neck motion, valsalva, pressure over C1-3 Absent/similar to migraine, but milder Decreased neck motion Anesthetic block, migraine tx, antiepiletic drugs, antidepressant (serotonin and norepinephrine reuptake inhibitors, NSAIDs Unilateral with sideshift Frontal, orbital, temporal, hemicranial 4-72 hrs Unilateral without sideshift Orbital, temporal Unilateral without sideshift Frontal, temporal, orbital, hemicranial Bilateral 15-180’ several times a day Multiple but neck Alcohol, HA occur motion not typical at predicitable times of day Nausea, Autonomic sx: vommitting, tearing, rhinorreha, phono/photophobia, ptosis, miosis, all visual scotoma ipsilateral to pain Constant with attacks None typically Days to weeks Typical migraine (ergots, triptans) Excellent response to indomethacin Oxygen, ergots, triptans Autonomic sx may occur F>M Frontal, occipital, circumferential Multiple but neck movement not typical Occasional decreased appetite, photo or phonophobia Simple analgesics, muscle relaxants, mediations used in migraine tx Cervicogenic Treatment Tree Limited ROM: Tx: Self stretches, PROM Joint Mobility Assessment: Central/U PAs cervical and thoracic, downglides, OA, AA* Tx: manips (per thoracic CPR or qualified cervical therapist), mobs *Test with Cervical Flexion Rotation Test (Hall 2010) and HEP of self rotation SNAGS (Hall 2007) Soft Tissue Assessment: Muscle Tension or TrP (UT, levator scap, suboccipitals, SCM, scalenes, paraspinals) Tx: STM, ischemic compression/suboccipital release, stretching, e-stim Strength/Endurance Assessment: Deep cervical flexors, scapular stabilizers Tx: strengthening/endurance TEs, NM re-ed** ** Test with Craniocervical Flexion Test (Harris et al 2005) and possible tx of low load cervical motor control TEs (Jull 2002) If Any Radicular Like Symptoms: Assess for Radiculopathy CPR, nerve tension tests, and/or TrP (ie: SCM, scalenes) Postural Assessment: Forward head, rounded shoulders, or of thoracic kyphosis or cervical lordosis Tx: postural/NM re-ed, biofeedback, pt education/ -ergonomics Further Pain Management: - Pt education for fear avoidance - Refer out for pharmacological/injection/behavior tx - Possible surgical intervention Cervicogenic Headache Diagnosis Hadelman et al (2001) Subjective Location of Pain Pain Characteristics Pain Increases With Objective Cervical ROM Palpable Findings Response to Blockade Radiologic Findings (possible) Neck Trauma Other Starts neck, occipital Ipsilateral, vague, nonradicular neck/shoulder/arm Occasional radicular symptoms Forehead, temporal, whole, frontal, orbital Unilateral without sideshift or Bilateral Moderate-severe Non-throbbing/ dull, aching Non-lancinating Becomes more continuous Varying duration Neck movement Posture Awkward head positioning Pressure over ipsilateral cervical/occipital area Decreased PROM Tender neck muscles Change in neck muscle properties Pain on C2/3 facet palpation and dermatome Occipital nerves, facets, or nerve roots abolish or relieve pain Flexion/extension abnormalities Fracture Congenital anomaly Tumor/rheumatoid arthritis, not spondylosis Possible Nausea, vomiting Edema, flushing Dizziness Phono/photophobia Blurred vision Dysphagia No effect with indomethacin, ergotamine, or sumatripan References Antonaci, Fabio, Torbjorn A. 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