Cephalalgia
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Cephalalgia. Department of Osteopathic Manipulative Medicine University of North Texas Health Science Center Texas College of Osteopathic Medicine. Cephalalgia. Stuart Williams, DO Associate Professor Department of Osteopathic Manipulative Medicine.

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Cephalalgia

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Cephalalgia

Department of Osteopathic Manipulative Medicine

University of North Texas Health Science Center

Texas College of Osteopathic Medicine


Cephalalgia

Stuart Williams, DO

Associate Professor

Department of Osteopathic Manipulative Medicine


A 32-year-old female presents to the office with a 10 year history of headaches. The headaches often begin with a sensation of flickering lights. Later she notes a throbbing sensation, usually right or left-sided. She also describes a pressure-like, tight sensation occurring in the occipital area.

Case Presentation


Case Presentation

When the headaches are severe, bright lights and strange smells may provoke or worsen the intensity. The patient will then prefer a dark room.

A severe headache in this patient will last several hours. She also describes a chronic, dull achy headache which has lasted several days.


ROS

  • No history of head trauma, seizure disorder, or CNS infections.

  • Family history of similar headaches in mother, and maternal grandmother.


Physical Examination

  • WDWN female in NAD

  • Alert, oriented x 3

  • Funduscopic – sharp discs, no hemorrhages, or exudates

  • PERRLA

  • CN 2-12 intact


Musculoskeletal

  • Tenderness, tightness suboccipital muscles

  • Elevated left 1st rib with surrounding spasm

  • Increased spasm in the cervical paravertebral mm. C3 – C5, RR SR

  • AA – RR

  • OA – SR RL

  • T1 – T4Increased sympathetic tone, loss of normal kyphotic curvature, SR RL


Diagnosis

Mixed

Tension / Migraine

Headaches


Differential Diagnosis

  • Migraine Headache

  • Tension Headache

  • Cluster Headache


Secondary Headache (Differential)

  • Glaucoma

  • Cerebral Aneurysm

  • Temporal Arteritis

  • Optic Neuritis

  • Carotid or Vertebral a. dissection

  • TMJ Syndrome

  • Herpes Zoster

  • Meningitis/Encephalitis

  • Sinusitis/Facial Osteomyelitis


Secondary Headache (Other Causes)

  • Intracranial Hypertension

  • Benign Intracranial Hypertension

  • Exertional Headache (Lift, Cough, Strain)

  • Normal Pressure Hydrocephalus

  • Myofascial Pain Syndrome

  • Subarachnoid Hemorrhage

  • Subdural Hematoma

  • Viremia


Secondary Headache (Other Causes)

  • Stroke

  • Vasculitis

  • Cervical Spine Disorder

  • Dental Disorder

  • Anemia

  • Caffeine Withdrawal

  • Fever

  • Hypercapnea

  • Hypoxia


Treatment

  • Zomig, 2.5 mg at onset of headache

    Repeat x1 in 2 hours if headache is not resolved

  • Naprosyn 500 mg p.o. Bid. p.c.


Mixed Headache with associated Cervical Pain

  • Very common in primary care

    What can be done osteopathically?


Mixed Headache with associated Cervical Pain

Musculoskeletal

SNS & PNS

Respiratory and Lymphatic


Headache

  • Most common headache is tension.

  • Many patients with migraine headache have coexisting tension headache.


Trigeminal Nucleus Caudalis

  • Major Relay Nucleus for head and neck pain.

  • Vascular Headache (Migraine)

    • Nociceptors Vascular

    • Nonnoxious Stimuli Vascular Pulsations

  • Tension Headache

    • Nociceptors Myofascial

    • Nonnoxious Stimuli Muscle Contractions


Trigeminal Nucleus Caudalis


Trigeminal Nucleus Caudalis


Trigeminal Nerve: Schema


Autonomic Nervous System Involvement

  • Parasympathetic

    • Vagus Nerve (CN X)


Vagus Nerve: Schema


Cranial Nerve Nuclei in Brainstem: Schema


Cranial Nerves: Schema


Autonomic Nervous System Involvement

  • Sympathetic

    • T1 – T4 ascend to cervical region


Autonomic Nervous System Involvement


Autonomic Nervous System Involvement


Sympathetic Nervous System


Areas to Treat Osteopathically

  • Sympathetic

    • Lower Cervical

    • Upper T-Spine

    • Associated ribs and myofascial attachments

  • Parasympathetic

    • Suboccipital Region


Treatments Soft Tissue

  • Soft Tissue

    • Cervical Spine Push-Pull

    • Thoracic Spine Trapezius, Rhomboids


Treatments – Soft Tissue (Cervical) Push – Pull


Rhomboid Stretch


Treatments - Soft Tissue (Thoracic Paravertebral)


Treatments – Soft TissueSNS


Treatments – Soft TissueTrapezius and Rhomboid Stretch


Rhomboid Stretch


Treatments Muscle Energy

  • Muscle Energy

    • Trapezius and related muscles

    • Cervical Muscles


Treatments Muscle Energy (Trapezius)


Treatments – Soft TissueCervical


Treatments Suboccipital Inhibition

  • Suboccipital Inhibition

    • Pads of fingers just beneath superior nuchal line in suboccipital soft tissue.

    • Weight of head rests on pads of fingers.


Treatments Suboccipital Inhibition


Treatments Suboccipital Inhibition


Suboccipital Decompression


Treatments 1st Rib Muscle Energy

  • 1st Rib Muscle Energy

    • Pads of thumbs on rib heads directly in front of trapezius.

    • Patient should shrug both shoulders towards ears while taking a deep breath.

    • Patient should release breath slowly while letting shoulders down.

    • Continue maintaining firm caudad pressure and follow the rib caudally through exhalation maintaining new position. (Barrier)


Treatments1st Rib Muscle Energy


TreatmentsCervical Muscle Energy

  • Diagnosis of Somatic Dysfunction

    • C-Spine

    • Side-bending

    • Rotate each segment


TreatmentsCervical Muscle Energy

  • Cervical Muscle Energy (C2 – C7)

    • Induce side-bending to restrictive barrier with pad of thumb.

    • Flex or extend neck to localize to particular segment.

    • Have patient side-bend away from barrier.

    • Side-bend patient to new restrictive barrier.


TreatmentsCervical Muscle Energy


TreatmentsCervical Muscle Energy


TreatmentsCervical Muscle Energy


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