n General Statistics
n Second most common complaint after back pain
n “Everyone” has headaches (HA)
n More than 80 million ER visits in U.S. per year
n Frequency of HA due to rich nerve supply and psychological implications of head pain
n General Statistics
n Nerves responsible for HA have their source from myelinated C fibers and A-delta fibers in cranial nerves V, IX, X, and roots C1, C2, C3
n Pain sensitive structures include the eye, ear, paranasal sinuses, large extra and intra cranial arteries, dural sinuses, periosteum of the skull skin, cranial muscles, and the upper cervical spine
n Etiologies
n Commonly overlooked etiologies include: food, fever, viral, metabolic, withdrawal, and pharmaceutical
n International Headache Society Classifications (see attachment)
n History: Questions to ask
n Character of pain
n Mode of onset
n Mode of offset
n Time of onset
n Relieving factors
n Aggravating factors
n History: Questions to ask
n Precipitating factors
n Frequency of attacks
n Duration of attacks
n Associated symptoms
n Family history of headache
n Allergies
n Seven danger signals of an ominous headache
n A “first” headache
n Headache due to exertion
n Headache with fever
n Headache in a drowsy or confused patient
n Seven danger signals of an ominous headache
n Headache in a patient with nuchal rigidity or meningeal signs
n Headache in a patient with abnormal physical signs
n Headache in a patient who “looks ill”
n Physical Exam
n Gait assessment
n Vital signs
n Fundoscopic exam
n Facial symmetry
n Head & Neck structures
n Deep tendon reflexes
n Plantar response
n Limb strength
n Relevant Muscles
n Trapezius
n Sternocleidomastoid
n Temporalis
n Occipitofrontalis
n Suboccipital muscles
n Masseter
n Relevant Muscles
n Medial & Lateral Pterygoid
n Anterior & Posterior Digastric
n Fascial muscles
n Splenius Capitis
n Posterior Cervical musculature
n Deep Anterior Cervical musculature
n Cervical Dysfunction
n Upper cervical nerves posses fibers for pain from the lower part of the occipital sinus, vertebral and posterior meningeal arteries, and the dural floor of the posterior fossa (C1, C2, C3)
n Differential Diagnosis:Migraine Headache
Etiology:
n Hereditary component
n Not correlated with personality types “A” or neuroses
n The worsening or migraine that occurs during periods of intense nervousness, anxiety, and depression is usually due to the superimposition of a tension headache
n Vascular spasm followed by vasodilatation
n Migraine Headache:Signs & Symptoms
Classic Migraine
n Character: throbbing pain
n Location: hemicranial
n Associated: preceded with visual disturbances and less often with hemi-sensory disturbances, hemiparesis, or aphasia
n Migraine Headache:Signs & Symptoms
Classic & Common Migraine
n Character: throbbing pain
n Location: hemicranial
n Associated: photophobia and or phonophobia; tension headache often concomitant
n Aggravated: red wine, nuts, aged cheese, chocolate and caffeine containing beverages
n Risk factor: women are more affected than men
n Migraine Headache:Diagnosis & Treatment
n Response to ergot therapy
n Drug treatment is widely varied (caffeine, NSAIDS, barbiturates, narcotics, beta blockers, calcium channel blockers, sedatives, and more…)
n Prevention by avoiding predisposing factors, decreasing stress, maintaining sleep regularity
n Osteopathic treatment would include stabilizing vasculature and associated concomitant tension headache
n Differential Diagnosis:Cluster Headache
Etiology
n Disturbed hypothalamic biorhythm
n Excess smoking and drinking may precipitate via sphenopalatine irritation
n Hemicranial (unilateral) cranial dysfunction
n Cervical somatic dysfunction with irritation of the spinal accessory nerve
n Cluster Headache:Signs & Symptoms
n Character: excruciating pain often stabbing
n Location: usually near one eye
n Associated: tearing, flushed face, nasal congestion, conjunctival congestion (ANS)
n Risk factor: males affected more than females
n Onset: begins at 20 – 40 years of age
n Cluster Headache:Signs & Symptoms
n Attacks last 30 – 90 minutes daily for days and then disappear for months (Headache “vacation”)
n Alcohol can precipitate but only during an active cycle, not during “vacations”
n Some are so painful that they can lead to suicide
n Cluster Headache: Prevention & Treatment
n Drug treatment is widely varied
n Osteopathic treatment would include a thorough cranial assessment
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Etiology
n Ruptured aneurysm
n Arteriovenous malformation
n Trauma
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Signs & Symptoms
n Character: full-blown catastrophic headache
n Location: Holocaine
n Duration: continuous
n Associated: photophobia, retinal hemorrhages, nuchal rigidity, Brudzinski’s sign, Kernig’s sign, obtunded collapse
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Diagnosis
n CT may show blood and aneurysm
n Lumbar puncture may show bloody CSF
n MRI
n Differential Diagnosis:Organic origin, Meningitis
Etiology
n Virus
n Bacteria
n Fungus
n Tuberculous
n Differential Diagnosis:Organic origin, Meningitis
Signs & Symptoms
n Character: cephalgia is intense, steady, and deep
n Location: holocranial pain associated with retro-orbital pain which is aggravated with eye movement
n Onset: sub-acute or acute
n Associated: fever, generalized convulsions, varied levels of consciousness, nuchal rigidity, Brudzinski and Kernig’s signs
n Differential Diagnosis:Organic origin, Meningitis
Diagnosis
n Headache with fever and nuchal rigidity
n LP reveals pleocytosis, increased protein, and low glucose
n CT scan after Tx is underway to R/O brain abscess and subdural empyema
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Etiology
n Increased volume
n Increased venous pressure
n Obstruction to flow/absorption of CSF
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Signs & Symptoms
n HA is severe
n HA occur with coughing, sneezing, valsalva effort
n Associated findings include papilledema, obtunded, focal neurologic signs & symptoms
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Diagnosis
n CT
n MRI
n Avoid LP
n Differential Diagnosis:Organic origin, Hypertension
n Usually no HA’s until DBP > 120 mm Hg
n 3 major causes of acute severe hypertension: drugs, pheochromocytoma, neurogenic (paraplegia)
n Associated findings include: retinopathy, convulsions, confusion or stupor evolving over several days
n Differential Diagnosis:Organic origin, Vasculopathies
Etiology
n Temporal (giant cell) arteritis
n Dissection of a vessel
n Differential Diagnosis:Organic origin, Vasculopathies
Signs & Symptoms of Temporal Arteritis
n Character: throbbing and sharp, burning pain
n Location: focal headache in the temporal or frontal-occipital region
n Onset: gradual and progressive
n Aggravated: headache worse at night and with cold
n Risk: most common in white females > 50 years old
n Associated: weight loss, fever, fatigue, polymyalgia rheumatica, monocular visual loss, jaw claudication
n Differential Diagnosis:Organic origin, Vasculopathies
Diagnosis of Temporal arteritis
n Increased sed rate
n Biopsy
n Differential Diagnosis:Organic origin, Vasculopathies
Signs & Symptoms (Dissection of vessel)
n Severe, localized HA
n History of trauma or vigorous exertion
n Diagnosis with CT
n Differential Diagnosis:Organic origin, Acute Purulent Sinusitis
n Involving the frontal, maxillary, sphenoidal, or ethmoidal sinuses
n True “sinus HA” is rare; if present, the patient is usually very ill, with a severe localized HA for hours or days, PND & tender sinuses; often misdiagnosed as tension HA or common migraine but may have these as concomitant HA
n Diagnosis: CT
n Differential Diagnosis:Tension HeadacheEtiology
Skeletal components
n Somatic dysfunctions of the upper cervical unit are going to impinge on the upper cervical nerves which have afferents in the cranium and dura
n Differential Diagnosis:Tension HeadacheEtiology
Muscular components
n Can be explained by trigger point reflex mechanisms. A myofascial trigger point is a focus of hyperirritability within a taut band of skeletal muscle or the associated fascia that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception
n Differential Diagnosis:Tension HeadacheEtiology
Muscular components
n Trigger points can result directly from ischemia due to chronically tense muscles, acute overload, overwork fatigue, direct trauma, and chilling.
n Trigger points can result indirectly from other trigger points (a.k.a. latent trigger points), visceral disease, arthritic joints, and by emotional distress
n Differential Diagnosis:Tension HeadacheEtiology
Soft tissue components
n Ligaments can refer pain to sclerotomes which need to be addressed to completely resolve the somatic dysfunction
Lymphatics
n Need to free up the thoracic inlet to allow drainage of fluids
n Trapezius
n The trapezius can have many trigger points but the ones located in the upper fibers are most relevant for cephalgia
n Pain referral pattern: Posterolateral aspect of the neck, mastoid process, temple and back of the orbit, and the angle of the jaw
n Trapezius
n The patient can often be misdiagnosed as having cervical radiculopathy or atypical facial neuralgia. The normally minimal antigravity function of the upper trapezius is overstressed by any position or activity in which the trapezius helps to carry the weight of the arm for a prolonged period
n The muscle can also be strained by chronic injury due to overload, carrying a heavy backpack, long telephone calls, and sleeping prone with the head turned to one side
n Trapezius
n The trapezius can also entrap the greater occipital nerve which enervates the skin of the scalp and the semispinalis capitis muscle
n Sternocleidomastoid Sternal division
n Pain referral pattern: supra-orbital and deep within the orbit, occipital ridge, and vertex
n Associated autonomic findings: excessive lacrimation, reddening of the conjunctiva, apparent “ptosis,” and visual disturbances
n Sternocleidomastoid Clavicular division
n Pain referral pattern: frontal area which extends across the forehead to the other side, and posterior auricular
n Associated proprioceptive findings: spatial disorientation
n Sternocleidomastoid
n The SCM trigger points can be activated by sleeping on two pillows and keeping the neck in a flexed position, or by keeping the neck in an extended position as in painting a ceiling or sitting in the front row of a theater with a high screen or elevated stage. The SCM is often injured in a “whiplash” injury that might occur in an automobile crash.
n Temporalis
n Pain referral pattern: widely throughout the temple, along the eyebrow, and behind the eye
n Temporalis trigger points may be activated by bruxism, direct trauma such as a fall or an impact to the cranium. The temporalis muscle can also be activated secondary to spasm in the masseter muscle
n Occipitofrontalis
n Frontal division pain referral pattern: upward and over the forehead on the ipsilateral side
n Occipital division pain referral pattern: laterally, diffusely over the back of the head and with pain deep in the orbit
n Second most common complaint after back pain
n “Everyone” has headaches (HA)
n More than 80 million ER visits in U.S. per year
n Frequency of HA due to rich nerve supply and psychological implications of head pain
n General Statistics
n Nerves responsible for HA have their source from myelinated C fibers and A-delta fibers in cranial nerves V, IX, X, and roots C1, C2, C3
n Pain sensitive structures include the eye, ear, paranasal sinuses, large extra and intra cranial arteries, dural sinuses, periosteum of the skull skin, cranial muscles, and the upper cervical spine
n Etiologies
n Commonly overlooked etiologies include: food, fever, viral, metabolic, withdrawal, and pharmaceutical
n International Headache Society Classifications (see attachment)
n History: Questions to ask
n Character of pain
n Mode of onset
n Mode of offset
n Time of onset
n Relieving factors
n Aggravating factors
n History: Questions to ask
n Precipitating factors
n Frequency of attacks
n Duration of attacks
n Associated symptoms
n Family history of headache
n Allergies
n Seven danger signals of an ominous headache
n A “first” headache
n Headache due to exertion
n Headache with fever
n Headache in a drowsy or confused patient
n Seven danger signals of an ominous headache
n Headache in a patient with nuchal rigidity or meningeal signs
n Headache in a patient with abnormal physical signs
n Headache in a patient who “looks ill”
n Physical Exam
n Gait assessment
n Vital signs
n Fundoscopic exam
n Facial symmetry
n Head & Neck structures
n Deep tendon reflexes
n Plantar response
n Limb strength
n Relevant Muscles
n Trapezius
n Sternocleidomastoid
n Temporalis
n Occipitofrontalis
n Suboccipital muscles
n Masseter
n Relevant Muscles
n Medial & Lateral Pterygoid
n Anterior & Posterior Digastric
n Fascial muscles
n Splenius Capitis
n Posterior Cervical musculature
n Deep Anterior Cervical musculature
n Cervical Dysfunction
n Upper cervical nerves posses fibers for pain from the lower part of the occipital sinus, vertebral and posterior meningeal arteries, and the dural floor of the posterior fossa (C1, C2, C3)
n Differential Diagnosis:Migraine Headache
Etiology:
n Hereditary component
n Not correlated with personality types “A” or neuroses
n The worsening or migraine that occurs during periods of intense nervousness, anxiety, and depression is usually due to the superimposition of a tension headache
n Vascular spasm followed by vasodilatation
n Migraine Headache:Signs & Symptoms
Classic Migraine
n Character: throbbing pain
n Location: hemicranial
n Associated: preceded with visual disturbances and less often with hemi-sensory disturbances, hemiparesis, or aphasia
n Migraine Headache:Signs & Symptoms
Classic & Common Migraine
n Character: throbbing pain
n Location: hemicranial
n Associated: photophobia and or phonophobia; tension headache often concomitant
n Aggravated: red wine, nuts, aged cheese, chocolate and caffeine containing beverages
n Risk factor: women are more affected than men
n Migraine Headache:Diagnosis & Treatment
n Response to ergot therapy
n Drug treatment is widely varied (caffeine, NSAIDS, barbiturates, narcotics, beta blockers, calcium channel blockers, sedatives, and more…)
n Prevention by avoiding predisposing factors, decreasing stress, maintaining sleep regularity
n Osteopathic treatment would include stabilizing vasculature and associated concomitant tension headache
n Differential Diagnosis:Cluster Headache
Etiology
n Disturbed hypothalamic biorhythm
n Excess smoking and drinking may precipitate via sphenopalatine irritation
n Hemicranial (unilateral) cranial dysfunction
n Cervical somatic dysfunction with irritation of the spinal accessory nerve
n Cluster Headache:Signs & Symptoms
n Character: excruciating pain often stabbing
n Location: usually near one eye
n Associated: tearing, flushed face, nasal congestion, conjunctival congestion (ANS)
n Risk factor: males affected more than females
n Onset: begins at 20 – 40 years of age
n Cluster Headache:Signs & Symptoms
n Attacks last 30 – 90 minutes daily for days and then disappear for months (Headache “vacation”)
n Alcohol can precipitate but only during an active cycle, not during “vacations”
n Some are so painful that they can lead to suicide
n Cluster Headache: Prevention & Treatment
n Drug treatment is widely varied
n Osteopathic treatment would include a thorough cranial assessment
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Etiology
n Ruptured aneurysm
n Arteriovenous malformation
n Trauma
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Signs & Symptoms
n Character: full-blown catastrophic headache
n Location: Holocaine
n Duration: continuous
n Associated: photophobia, retinal hemorrhages, nuchal rigidity, Brudzinski’s sign, Kernig’s sign, obtunded collapse
n Differential Diagnosis:Organic origin, Subarachnoid hemorrhage
Diagnosis
n CT may show blood and aneurysm
n Lumbar puncture may show bloody CSF
n MRI
n Differential Diagnosis:Organic origin, Meningitis
Etiology
n Virus
n Bacteria
n Fungus
n Tuberculous
n Differential Diagnosis:Organic origin, Meningitis
Signs & Symptoms
n Character: cephalgia is intense, steady, and deep
n Location: holocranial pain associated with retro-orbital pain which is aggravated with eye movement
n Onset: sub-acute or acute
n Associated: fever, generalized convulsions, varied levels of consciousness, nuchal rigidity, Brudzinski and Kernig’s signs
n Differential Diagnosis:Organic origin, Meningitis
Diagnosis
n Headache with fever and nuchal rigidity
n LP reveals pleocytosis, increased protein, and low glucose
n CT scan after Tx is underway to R/O brain abscess and subdural empyema
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Etiology
n Increased volume
n Increased venous pressure
n Obstruction to flow/absorption of CSF
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Signs & Symptoms
n HA is severe
n HA occur with coughing, sneezing, valsalva effort
n Associated findings include papilledema, obtunded, focal neurologic signs & symptoms
n Differential Diagnosis:Organic origin, Increased Intracranial pressure
Diagnosis
n CT
n MRI
n Avoid LP
n Differential Diagnosis:Organic origin, Hypertension
n Usually no HA’s until DBP > 120 mm Hg
n 3 major causes of acute severe hypertension: drugs, pheochromocytoma, neurogenic (paraplegia)
n Associated findings include: retinopathy, convulsions, confusion or stupor evolving over several days
n Differential Diagnosis:Organic origin, Vasculopathies
Etiology
n Temporal (giant cell) arteritis
n Dissection of a vessel
n Differential Diagnosis:Organic origin, Vasculopathies
Signs & Symptoms of Temporal Arteritis
n Character: throbbing and sharp, burning pain
n Location: focal headache in the temporal or frontal-occipital region
n Onset: gradual and progressive
n Aggravated: headache worse at night and with cold
n Risk: most common in white females > 50 years old
n Associated: weight loss, fever, fatigue, polymyalgia rheumatica, monocular visual loss, jaw claudication
n Differential Diagnosis:Organic origin, Vasculopathies
Diagnosis of Temporal arteritis
n Increased sed rate
n Biopsy
n Differential Diagnosis:Organic origin, Vasculopathies
Signs & Symptoms (Dissection of vessel)
n Severe, localized HA
n History of trauma or vigorous exertion
n Diagnosis with CT
n Differential Diagnosis:Organic origin, Acute Purulent Sinusitis
n Involving the frontal, maxillary, sphenoidal, or ethmoidal sinuses
n True “sinus HA” is rare; if present, the patient is usually very ill, with a severe localized HA for hours or days, PND & tender sinuses; often misdiagnosed as tension HA or common migraine but may have these as concomitant HA
n Diagnosis: CT
n Differential Diagnosis:Tension HeadacheEtiology
Skeletal components
n Somatic dysfunctions of the upper cervical unit are going to impinge on the upper cervical nerves which have afferents in the cranium and dura
n Differential Diagnosis:Tension HeadacheEtiology
Muscular components
n Can be explained by trigger point reflex mechanisms. A myofascial trigger point is a focus of hyperirritability within a taut band of skeletal muscle or the associated fascia that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception
n Differential Diagnosis:Tension HeadacheEtiology
Muscular components
n Trigger points can result directly from ischemia due to chronically tense muscles, acute overload, overwork fatigue, direct trauma, and chilling.
n Trigger points can result indirectly from other trigger points (a.k.a. latent trigger points), visceral disease, arthritic joints, and by emotional distress
n Differential Diagnosis:Tension HeadacheEtiology
Soft tissue components
n Ligaments can refer pain to sclerotomes which need to be addressed to completely resolve the somatic dysfunction
Lymphatics
n Need to free up the thoracic inlet to allow drainage of fluids
n Trapezius
n The trapezius can have many trigger points but the ones located in the upper fibers are most relevant for cephalgia
n Pain referral pattern: Posterolateral aspect of the neck, mastoid process, temple and back of the orbit, and the angle of the jaw
n Trapezius
n The patient can often be misdiagnosed as having cervical radiculopathy or atypical facial neuralgia. The normally minimal antigravity function of the upper trapezius is overstressed by any position or activity in which the trapezius helps to carry the weight of the arm for a prolonged period
n The muscle can also be strained by chronic injury due to overload, carrying a heavy backpack, long telephone calls, and sleeping prone with the head turned to one side
n Trapezius
n The trapezius can also entrap the greater occipital nerve which enervates the skin of the scalp and the semispinalis capitis muscle
n Sternocleidomastoid Sternal division
n Pain referral pattern: supra-orbital and deep within the orbit, occipital ridge, and vertex
n Associated autonomic findings: excessive lacrimation, reddening of the conjunctiva, apparent “ptosis,” and visual disturbances
n Sternocleidomastoid Clavicular division
n Pain referral pattern: frontal area which extends across the forehead to the other side, and posterior auricular
n Associated proprioceptive findings: spatial disorientation
n Sternocleidomastoid
n The SCM trigger points can be activated by sleeping on two pillows and keeping the neck in a flexed position, or by keeping the neck in an extended position as in painting a ceiling or sitting in the front row of a theater with a high screen or elevated stage. The SCM is often injured in a “whiplash” injury that might occur in an automobile crash.
n Temporalis
n Pain referral pattern: widely throughout the temple, along the eyebrow, and behind the eye
n Temporalis trigger points may be activated by bruxism, direct trauma such as a fall or an impact to the cranium. The temporalis muscle can also be activated secondary to spasm in the masseter muscle
n Occipitofrontalis
n Frontal division pain referral pattern: upward and over the forehead on the ipsilateral side
n Occipital division pain referral pattern: laterally, diffusely over the back of the head and with pain deep in the orbit
Tidak ada komentar:
Posting Komentar