‘Tension Headache’ or ‘Migraine Without Aura’ or ‘Mixed’ Headache?
October 12, 2009 by dean · Leave a Comment
Diagnosis cannot be done from symptoms alone
This study from Spain demonstrates that diagnosing headache and migraine cannot be done from symptoms alone.
One hundred and five GPs were asked to examine and treat a patient who was considered (according to the International Headache Society’s diagnostic criteria) to be suffering migraine without aura.
Forty six diagnosed migraine correctly, 41 diagnosed the patient as tension-type headache, whilst 17 concluded ‘mixed’ headache and one GP was unable to diagnose the patient. One hundred and three recommended anti inflammatory medication as symptomatic treatment. Triptans were recommended by 67 GPs (including 15 of the 41 who had diagnosed the patient as tension-type headache). Preventive treatment was not considered by 30 GPs. A total of 66 GPs would prescribe beta-blockers (13 of the 41 who diagnosed tension-type headache), 35 amitriptyline (of whom 23 diagnosed tension-type headache) and the remaining 9, other treatments.
I have always maintained that a ‘diagnosis’ is not particularly useful – this study supports my clinical experience – what is the point of a diagnosis. The key to successful management is finding the source of the sensitisation; whilst the triptans may decrease the sensitisation they do not remove the source.
A skilled examination of the structures of the upper neck can identify relevant disorders – this involves temporary reproduction (and easing as the technique is sustained) of familiar head pain.
Cheers
Dean
(Pascual J, Sanchez A, Castillo J Dif?culties for diagnosing and treating migraine among general practitioners Cephalalgia 2009;29(Suppl. 1):1–166)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
A Tale of the Medical Practitioner and the Headache/Migraine Physiotherapist
October 11, 2009 by dean · Leave a Comment
I have mentioned the importance of educating you the headache and migraine sufferer as to what we as physiotherapists have to offer. This reminded me of a physiotherapist in The Netherlands who has completed both of my Level I and Advanced Level II courses.
When he returned to do the Level II course he recounted how when he had gone back to his village after the Level I course he wrote to his local doctors. He explained to them that he had done a ‘Watson Headache Course’, and that he was interested in treating their headache patients.
He described that initially only a couple of headache and migraine patients were referred and when they got better, he was referred more and then as his good results continued …. and now his work is almost exclusively headache and migraine.
A good result and a receptive and enlightened medical practitioner!
Cheers
Dean
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Cluster Headache and Migraine Are Just Different Expressions of the Same Condition
October 9, 2009 by dean · Leave a Comment
After examining six clinical trials in which cluster headache sufferers were treated with various ‘triptan’ medications it was concluded that the ‘triptans’ were effective in preventing the debilitating pain of cluster headache – just further evidence to support that cluster headache and migraine share a common underlying disorder.
This disorder has been demonstrated to be a sensitised brainstem and of course the ‘triptans’ de-sensitise the brainstem.
Furthermore there is a significant body of research which suggests that influencing (anaesthetising/blocking) information from structures of the upper neck prevents migraine and cluster headache. This suggests that abnormal information from disorders of these structures can sensitise the brainstem and that therefore a skilled examination of the upper neck should be included in assessment of migraine and cluster headache sufferers.
Cheers
Dean
(Akin Takmaz et al. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri. 2008 Jan;20(1):47-50
Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain 1996; 119:1419-28
Law S, Derry S, McQuay H, Moore A A systematic review of the triptan class of drugs for the treatment of cluster headache Cephalalgia 2009;29 (Suppl. 1):1–166
Nardone R et al Trigemino-Cervical Reflex Abnormalities in Patients with Migraine and Cluster Headache. Headache 2008; 48(4):578-585
Peres MF. et al Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522
Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
Solomon S, Lipton RB, Newman LC. Nuchal features of cluster headache. Headache 1990;30:347-9obin J,Stephen Flitman S. Nerve Blocks: When and What to Inject? Headache 2009
Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
Young et al Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125
Young et al. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1139)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Cluster Headache and Migraine Are Related
October 8, 2009 by dean · Leave a Comment
Cluster headache sufferers experience one or more migrainous features
In 155 cluster headache patients almost 25% experienced one or more migrainous features, including nausea/vomiting were present in 18.1%, photophobia (sensitivity to light) in 12.3%, phonophobia (sensitivity to sound) in 5.2%, osmophobia (sensitivity to smells) in 0.6% and aura in 2.6% of patients.
The authors suggest that migrainous features are common in cluster headache sufferers and that they are underestimated.
The results of this survey support my clinical experience, and the recent research, which demonstrates that the various forms of headache and migraine share a similar mechanism.
Cheers
Dean
(Zidverc-Trajkovic J, Sundic A, Radojicic A and Sternic N. Cluster headache: the signi?cance of the ‘‘migraineous’’ phenomena Cephalalgia 2009;29 (Suppl. 1):1–166)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Cervicogenic Headache is Rare – You Have Got to be Kidding (?)
October 7, 2009 by dean · Leave a Comment
In a study coming out of Norway the incidence of cervicogenic (neck) headache was found to be rare – only 0.17% of the population.
It is interesting to note that the diagnosis was made based only on the features of headache. It is widely accepted that features of headache alone are not sensitive enough to differentiate cervicogenic headache from migraine and from tension headache.
To diagnose cervicogenic headache, a thorough and skilled examination of the upper neck needs to be performed for temporary reproduction (and resolution) of familiar headache.
A physical examination was performed on only those headache sufferers selected on the basis of their headache features (and did include the above!). If it had it would have confirmed cervicogenic headache. However this is not the point, the physical examination was performed on only a select few!
Similarly, greater occipital nerve (GON) blocks blocks were performed only on those selected from their headache features – the blocks were effective in over 90% – I am not surprised. As with the physical examination, the blocks needed to be performed before a diagnosis of cervicogenic headache was made.
I have written before of the numerous studies demonstrating that headaches with a diagnosis of migraine are relieved by blocking the GON (greater occipital nerve) – who knows how many of the headache sufferers were excluded based on features and who had cervicogenic headache (?)
Previous research has shown that cervicogenic (neck) headache is as common as migraine.
Cheers
Dean
(Knackstedt H. Cervicogenic headache in the general population. the Akershus study of chronic headache. Cephalalgia 2009;29 (Suppl. 1):1–166
Nilsson N. The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine 1995;20:1884-1888
Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
Takmaz, S. et al Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri 2008 Jan;20(1):47-50
Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
Young WB, Marmura M, Ashkenazi A, Evans RW. Expert opinion: Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache. 2008;48:1122-1125
Young et al. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1139)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Migraine: To Treat or Not To Treat – The Dilemma!
October 5, 2009 by dean · Leave a Comment
….. this was the title of my second presentation at the CRAFT Conference in Nuremberg.
The traditional medical model is largely dismissive of the role of neck disorders in the migraine process. However my clinical experience of over 21000 hours with headache and migraine sufferers contradicts this view.
Now I do not expect people to accept my perspective without question but when the reply I get is:
“Well we don’t know where migraine comes from or what it is, but it can’t come from the neck.”
I get a just a little frustrated ….. think about this for a minute ….. if you don’t know where something is coming from you cannot say it does not come from the neck!
My reply is:
“Can you show me it doesn’t come from the neck?”
….. which of course they can’t.
In this presentation I put forward the evidence, the research (of which there is plenty), which shows quite clearly that neck disorders can be the key to the migraine process and how we as physiotherapists can identify this.
Cheers
Dean
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Neck Disorders in Migraine and Chronic Migraine Headache
October 1, 2009 by dean · Leave a Comment
Neck Disorders are frequently found in migraine sufferers
More evidence from a study in the US which shows that cervicogenic (neck) disorders are frequently found in Migraine and Chronic Migraine sufferers.
Using a special device, muscle tenderness was assessed and found to be significantly increased in both the migraine and chronic migraine groups when compared to non headache subjects.
Why is it that the conclusion was that muscle tenderness results from the migraine process and not the cause of the process?!!!
Cheers Dean
(Bevilaqua-Grossi D, Moreira VC, Canonica AC, Chaves TC, Goncalves MC, Florencio LL, Bordini CA2, Speciali JG, Bigal ME. Pain thresholds in craniocervical muscles in women with migraine, chronic migraine, and with no headaches. Cephalalgia 2009;29 (Suppl. 1):1–166)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.