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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

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


Case presentation

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 presentation1
Case Presentation 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.

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 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.

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

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


Physical examination
Physical Examination 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.

  • WDWN female in NAD

  • Alert, oriented x 3

  • Funduscopic – sharp discs, no hemorrhages, or exudates

  • PERRLA

  • CN 2-12 intact


Musculoskeletal
Musculoskeletal 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.

  • 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 – T4 Increased sympathetic tone, loss of normal kyphotic curvature, SR RL


Diagnosis
Diagnosis 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.

Mixed

Tension / Migraine

Headaches


Differential diagnosis
Differential Diagnosis 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.

  • Migraine Headache

  • Tension Headache

  • Cluster Headache


Secondary headache differential
Secondary Headache (Differential) 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.

  • 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
Secondary Headache 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. (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 causes1
Secondary Headache 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. (Other Causes)

  • Stroke

  • Vasculitis

  • Cervical Spine Disorder

  • Dental Disorder

  • Anemia

  • Caffeine Withdrawal

  • Fever

  • Hypercapnea

  • Hypoxia


Treatment
Treatment 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.

  • 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
Mixed Headache with associated Cervical Pain 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.

  • Very common in primary care

    What can be done osteopathically?


Mixed headache with associated cervical pain1
Mixed Headache with associated Cervical Pain 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.

Musculoskeletal

SNS & PNS

Respiratory and Lymphatic


Headache
Headache 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.

  • Most common headache is tension.

  • Many patients with migraine headache have coexisting tension headache.


Trigeminal nucleus caudalis
Trigeminal Nucleus Caudalis 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.

  • 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 caudalis1
Trigeminal Nucleus Caudalis 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.


Trigeminal nucleus caudalis2
Trigeminal Nucleus Caudalis 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.


Trigeminal nerve schema
Trigeminal Nerve: Schema 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.


Autonomic nervous system involvement
Autonomic Nervous System Involvement 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.

  • Parasympathetic

    • Vagus Nerve (CN X)


Vagus nerve schema
Vagus Nerve: Schema 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.


Cranial nerve nuclei in brainstem schema
Cranial Nerve Nuclei in Brainstem: Schema 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.


Cranial nerves schema
Cranial Nerves: Schema 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.


Autonomic nervous system involvement1
Autonomic Nervous System Involvement 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.

  • Sympathetic

    • T1 – T4 ascend to cervical region


Autonomic nervous system involvement2
Autonomic Nervous System Involvement 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.


Autonomic nervous system involvement3
Autonomic Nervous System Involvement 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.


Sympathetic nervous system
Sympathetic Nervous System 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.


Areas to treat osteopathically
Areas to Treat Osteopathically 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.

  • Sympathetic

    • Lower Cervical

    • Upper T-Spine

    • Associated ribs and myofascial attachments

  • Parasympathetic

    • Suboccipital Region


Treatments soft tissue
Treatments 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. Soft Tissue

  • Soft Tissue

    • Cervical Spine Push-Pull

    • Thoracic Spine Trapezius, Rhomboids


Treatments soft tissue cervical push pull
Treatments – Soft Tissue 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. (Cervical) Push – Pull


Rhomboid stretch
Rhomboid Stretch 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.


Treatments soft tissue thoracic paravertebral
Treatments - Soft Tissue 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. (Thoracic Paravertebral)


Treatments soft tissue sns
Treatments – Soft Tissue 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. SNS


Treatments soft tissue trapezius and rhomboid stretch
Treatments – Soft Tissue 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. Trapezius and Rhomboid Stretch


Rhomboid stretch1
Rhomboid Stretch 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.


Treatments muscle energy
Treatments 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. Muscle Energy

  • Muscle Energy

    • Trapezius and related muscles

    • Cervical Muscles


Treatments muscle energy trapezius
Treatments 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. Muscle Energy (Trapezius)


Treatments soft tissue cervical
Treatments – Soft Tissue 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. Cervical


Treatments suboccipital inhibition
Treatments 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. 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 inhibition1
Treatments 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. Suboccipital Inhibition


Treatments suboccipital inhibition2
Treatments 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. Suboccipital Inhibition


Suboccipital decompression
Suboccipital Decompression 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.


Treatments 1 st rib muscle energy
Treatments 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. 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)


Treatments 1 st rib muscle energy1
Treatments 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. 1st Rib Muscle Energy


Treatments cervical muscle energy
Treatments 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. Cervical Muscle Energy

  • Diagnosis of Somatic Dysfunction

    • C-Spine

    • Side-bending

    • Rotate each segment


Treatments cervical muscle energy1
Treatments 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. Cervical 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.


Treatments cervical muscle energy2
Treatments 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. Cervical Muscle Energy


Treatments cervical muscle energy3
Treatments 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. Cervical Muscle Energy


Treatments cervical muscle energy4
Treatments 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. Cervical Muscle Energy