What is a headache and how can Physio help?

A headache is described as a continuous painful sensation in the head that can range from sharp to dull. Headaches are relatively common, often leading to impaired function and decreased quality of life.¹

Headaches are classified into categories according to the International Classification of Headache Disorders (ICHD).1 This blog is going to focus on the headaches that are commonly seen by physiotherapists. Migraines and tension type headaches are commonly seen, however cervicogenic headaches are the most prominent in the population and present frequently. Physiotherapists are very effective at treating cervicogenic headaches and can make a significant difference in the frequency, intensity and duration of headaches and any associated neck pain.²

What are migraines?

Migraines are described as a recurrent headache disorder which affects 15 percent of the population aged 22-55 years.³ They commonly affect women more than men and generally begins in childhood to early adulthood, although sometimes starting later in life. Migraines have two major subtypes which are migraine with aura and migraine without aura. Aura refers to symptoms or sensations of flashing lights or changes to the vision with lines or blind spots.³

Migraines with aura are characterised by temporary symptoms of flashing lights, blind spots or changes in vision that usually precede or accompany a headache. They are described as recurrent attacks, lasting minutes of one sided visual, sensory or other symptoms that are followed by a headache. Migraines with aura account for about 10-20% of migraine sufferers which are diagnosed by: ¹

1.     Having at least two attacks matching the symptoms

2.     One or more aura symptoms such as changes in vision, sensitivity to light, sensitivity to sound, nausea, numbness and changes in speech.

3.     At least one aura symptom spreading over about 5 minutes with another symptom occurring in succession.

4.     The aura is accompanied or followed by a headache within one hour.

Migraines without aura are characterised by a headache with specific features and associated symptoms. They are described as a recurrent headache disorder with attacks lasting 4-72 hours on one side of the head in a throbbing pattern. These headaches differ from other migraines as they do not display aura symptoms. Migraines without aura, however, may have nausea, vomiting, photophobia (sensitivity to light) and/or phonophobia (unwanted loud noise) associated with the headache.¹⁻³ They are diagnosed by:

1.     Having at least five attacks matching the symptoms

2.     The headache lasting 4-72 hours

3.     Having a throbbing pain on one side of the head with moderate to severe intensity aggravated by routing physical activity (walking)

4.     Having at least one symptom of vomiting, nausea, photophobia and/or phonophobia

What are tension type headaches (TTH)?

Tension type headaches impose a heavy burden on the global population due to their prevalence but remains poorly managed and partially understood. They are the most common out of the primary headaches and their lifetime prevalence ranges from 30-78%.⁴ TTH are a neurological disorder characterised by a number of attacks ranging from mild to moderate headache intensity with associated symptoms.⁵

TTH are episodes of headaches that is often recognised by a feeling of a tight band around the head. They are typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia (sensitivity to light) or phonophobia (unwanted loud noise) may be present.⁴⁻⁵ The following criteria is used to diagnose TTH: ¹

1.     Lasting from 30 minutes to 7 days

2.     Characteristics of pain on both sides of the head of , mild to moderate intensity that is not aggravated by routine physical activity (walking)

3.     A feeling of pressing or tightening

4.     No nausea or vomiting

5.     Either photophobia or phonophobia

TTH can be categorised further depending on the frequency of the headaches, but treatment for them remains the same.

What are Cervicogenic Headaches (CGH)?

CGH are a secondary headache that are caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.²

CGH affect 2.5 to 4.1 percent of the general population, however, this figure rises to 15 to 20 percent of people who report headaches. There is evidence to suggest that it has a similar impact on the quality of life as migraines and tension-type headaches.¹⁻² About 70% of cases of CGH, involve pathology of the C2-3 zygapophyseal joint, making it the greatest cause for pain and headaches.⁷

CGH are characterised by unilateral pain, sign and symptoms of neck involvement due to reduced range of motion or neck movements causing pain. People with CGH tend to have increased trigger points in the upper trapezius, levator scapulae, scalenes and suboccipital muscles with a weakness in the deep neck flexors.⁶ CGH are demonstrated by at least two of the following: ¹

1.     headache has developed in the temporal region related to the onset of a cervical disorder (neck pain or decreased range of motion)

2.     headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder (neck pain or range of motion)

3.     cervical range of motion is reduced and headache is made significantly worse by provocative manoeuvres

What structures are involved?

The cervical spine consists of 7 vertebrae, C1 to C7, the cervical nerves from C1 to C8, muscles and ligaments.

The first two vertebrae have a unique shape and function which forms the upper cervical spine. C1, known as the atlas, articulates with the occiput (base of the skull) . It is responsible 33% of flexion and extension, forward and backward movement of the head. The axis, C2, forms with atlas which acts as a pivot and is reliable for 60% of rotation movements within the neck.⁷

The C1-C3 nerves relay pain signals to the head and neck, via the connection to the central nervous system and brain stem (connection of the brain to the spinal cord). As a result of these connections the neck can be seen as a cause for referred pain to various regions around the face, neck and/or eyes during headaches.

The 5 cervical vertebrae that make up the lower cervical spine, C3-C7, are similar to each other but very different from C1 and C2.

Management

Physiotherapists and other manual therapists treat patients with headaches when musculoskeletal dysfunction is the likely source or a significant contributing factor. Techniques are usually applied to the cervical and thoracic spines and evidence suggests that manual therapy, therapeutic exercise, advice and education may reduce headache intensity, frequency and disability.⁸

When considering outcome measures for physical treatment of headache in clinical trials and practice, the parameters of headache frequency, duration and intensity are often used

In keeping with a patient centred approach to management, it is essential for the therapist to appreciate and be able to measure the effect that a patient's headaches have on their quality of life.⁹

Exercises

Three key exercises for headache relief revolve around the precipitating factors for the cause of the headaches.

1.     Chin Tucks:

Headaches are generally caused by poor posture with head forward and shoulders hunched over. This poor posture increases stress on the cervical spine and its supporting structures. Chin tucks are a great way to align your head, neck and shoulders. When performed correctly and completed regularly they can help improve the neck’s strength, flexibility, and function. They are aimed at strengthening the deep cervical flexors, lower cervical extensors and other muscles that keep the head pulled back in good posture and stretch the scalene and suboccipital muscles.

2.     Scapular protraction and retraction

This exercise is similar to the chin tuck exercise and is very useful in reducing the head forward and shoulders hunched posture. By protracting and retracting the shoulder, the muscles in between the shoulder blades strengthen promote movement and good posture.

3.     Trapezius Stretch

As a result of neck pain and stiffness the muscles around the neck can become really tight. The trapezius muscle is a large muscle on either side of the neck that extends from the cervical vertebrae to the shoulder.

By stretching this muscle on both sides of the neck, it can relieve some muscle tightness which promotes more movement through the neck, easing headaches.

References: 

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jun 14; 33(9): 629–808. DOI: https://doi.org/10.1177/0333102413485658

2. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic Headache: Diagnostic Criteria. Headache: The Journal of Head and Face Pain. 1998 Jun; 38(6): 442–5. DOI: https://doi.org/10.1046/j.1526-4610.1998.3806442.x

3. Goadsby P. Pathophysiology of migraine. Annals of Indian Academy of Neurology. 2012; 15(5): 15-22. DOI: https://doi.org/10.4103%2F0972-2327.99993

4. Chen Y. Advances in the pathophysiology of tension-type headache: From stress to central sensitization. Current Pain and Headache Reports. 2009 Dec; 13(6): 484–94. DOI: https://doi.org/10.1007/s11916-009-0078-x

5. Bendtsen L. Central Sensitization in Tension-Type Headache—Possible Pathophysiological Mechanisms. Cephalalgia. 2000 Jun; 20(5): 486–508. DOI: https://doi.org/10.1046/j.1468-2982.2000.00070.x

6. Page P. Cervicogenic headaches: an evidence-led approach to clinical management. The International Journal of Sports Physical Therapy. 2011 Sep; 6(3) 254-266.

7. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology. 2009 Oct; 8(10): 959–68. DOI: https://doi.org/10.1016/s1474-4422(09)70209-1

8. Watson DH, Trott PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia: An International Journal of Headache. 1993 Aug 1; 13(4): 272–84; discussion 232. DOI: https://doi.org/10.1046/j.1468-2982.1993.1304272.x

9. Bini P, Hohenschurz-Schmidt D, Masullo V, Pitt D, Draper-Rodi J. The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis. Chiropractic & Manual Therapies. 2022 Nov 23; 30(1). DOI: https://doi.org/10.1186/s12998-022-00459-9