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Headaches and Treatment Options By Matthew A. Buck, SPT
Quick Links: 46% of our population suffers from headaches1. The World Health Organization has ranked headaches as one of the top ten medical conditions that cause disability1. With today’s high stress levels, lack of activity, and overreliance on medication, these statistics are not surprising. The purpose of this article is to provide a general description of what a headache is, explain the various types of headaches, describe potential causes and common symptoms of headaches, and highlight the treatment options including physical therapy to manage and prevent headaches. Headache: Pain in the head that may be felt over the back of the head, sides of the head, above the eyes and/or in the neck. Symptoms will vary with different types of headaches. Trigger: An event or experience that leads to the onset of the headache. Symptom: Something that the patient feels or experiences with a condition. A common symptom is pain. Headaches are classified as primary or secondary. Primary headaches are more common and are not a result of a disease or underlying medical condition3,4. The most common types of primary headaches are migraine without aura, migraine with aura, tension, and cluster headaches. Of these types, tension headaches are the most common1. Secondary headaches are a result of a medical condition such as a tumor, disease, or infection, or are related to the use of medication4. Headaches of this type are rare but often require more urgent medical attention. Despite the many different types of headaches, the majority are not a serious medical problem. Concern arises when very severe headaches begin in people over 50 years old. For more detailed information on the different types of headaches, the International Headache Society (IHS) offers excellent information on the classification of headaches. A link is provided below.Determining the cause or causes of your headache will help establish what type of headache you are experiencing. The cause(s) of your headache are best identified from an evaluation of your age, frequency of headaches, triggering events, pain characteristics and physical examination by a healthcare provider. When the cause is unidentified after an examination, a diagnostic test such as an MRI (magnetic resonance imaging) may be done to help find the cause of your pain. Listed below are some general causes of headaches:
Pain and other symptoms help determine what type of headache you’re experiencing. It’s important when talking with a healthcare provider that you give an accurate description of the symptoms you are experiencing. The following are common questions that may be asked by your healthcare provider: ▪ How severe is the pain you’re experiencing? ▪ How frequent are your headaches? ▪ Where is your pain located? ▪ Does the pain radiate to your forehead? ▪ Do bright lights or loud noises bother you when you have a headache? ▪ Do you have pain in your neck? ▪ Is your pain pulsating or feel like its vibrating? ▪ Do you take medications for pain relief on a daily basis? ▪ Do you experience a headache when pain medication is not taken? ▪ Have you noticed that you get headaches after certain events? ▪ Do headaches occur around your menstruation cycle? ▪ Does your headache prevent you from going to work or doing normal activities? The correct treatment choice depends on the type and severity of your headache. Many people rely on medication to manage their headaches. Medications are used to treat the pain and symptoms, stop a current headache, or prevent future headaches (anti-depressants, etc). For an occasional headache with mild pain, over the counter pain relievers are the most popular option5. This option can be effective in quickly reducing pain and allowing one to go on with normal functioning. Overreliance on medications to treat pain and taking higher than necessary dosages can lead to dependence on pain medication and to rebound headaches6. Tolerance to medication may also develop, in which higher than usual dosages much be taken to feel relief . The other problem with taking pain medications is that you may be treating the symptoms, while neglecting the actual cause.Oftentimes, people have success managing the frequency of their headaches when they begin to identify triggers that cause headaches7. For this reason, it is common for healthcare providers to ask you to keep a headache diary to help confirm a diagnosis7. This is accomplished by writing down events that occur prior to, during, and following each headache. Over time, patterns and causative factors can be observed and then avoided. If, for example, a patient journals that they have a headache that begins each morning along with neck stiffness, it may be determined that the cause may be sleeping with the head positioned poorly from too many pillows or other awkward sleep positions. Perhaps you identify that headaches are typically felt after long stressful days. In this case a tension headache may be present. Females may also discover many headaches are experienced around menstruation periods. Explanations for this occurrence may involve a change in estrogen levels8. These are examples of how a headache diary can be effective in determining causes or situations that trigger headaches. People who have headaches associated with neck pain, trauma, or poor posture may benefit from physical therapy9,1,110. Tension type headaches or headaches associated with mechanical pain may be most appropriately treated with physical therapy. Poor posture or weak muscles in the neck are the main causes of mechanical pain11. Therapy will work on correcting neck posture (see figure 1 and 2), strengthening weak muscles, and increasing flexibility. Exercises can help improve posture and restore muscle functioning. Neck retractions (see figure 3 and 4) are an example of a commonly used posture exercise. When neck retractions are done over time they can lead to correct neck posture and normal muscle functioning.Manual therapy has also been shown to be effective in treating headaches9,10. Common examples of manual treatments include massage, range of motion exercises, joint mobilizations, and manipulation of the neck. Other physical therapy treatments may include relaxation techniques and modalities (ice, heat, electrical stimulation, lasers) to promote relaxation and reduce pain. Research has shown that a combination of neck exercises with manual therapy offers the most effective treatment plan9,10. Because all pain is unique, treatment is aimed at what is causing the patient’s problems.
Figure 1 Poor Neck Posture (Forward Head Posture) Figure 2 Correct Posture of Neck
Figure 3 Starting position for neck retractions Figure 4 End Position for neck retractions
Only a licensed healthcare provider can diagnose what type of headache you are experiencing. Based on the diagnosis, an individualized treatment plan would be initiated by your healthcare provider. The purpose of this article was to show that there is a wide variety of headaches and treatment options. When possible, prevention of headaches should be a goal which may consist of managing stress levels, being active, awareness of triggering events, keeping a headache diary, and living a healthy lifestyle. The second purpose of this article was to introduce the use of physical therapy as a tool to treat certain headache types. This approach aims to treat the actual cause of the headache which is critical in preventing future headaches. If your healthcare provider suggests that you may be experiencing a tension headache or headache with mechanical pain, ask about physical therapy as a treatment option. External Links for more information on headaches: http://ihs-classification.org/en/ http://www.americanheadachesociety.org/ References: 1. Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193-210. 2. Merriam-Webster Online Dictionary. 2008. Available at: http://www.merriam- webster.com/dictionary/headache. Accessed October 20th, 2008. 3. Lipton RB, Bigal ME, Steiner TG, Silberstein SD, Olesen J. Classification of primary headaches. Neurology. 2004;63:427-435. 4. International Headache Society. 2008. Available at: http://ihs-classification.org/en/. Accessed October 20th, 2008. 5. Martelletti P, Suijlekom H. Cervicogenic Headache: Practical Approaches to Therapy. CNS Drugs. 18(12):793-805, 2004. 6. Rapoport A, Stang P, Gutterman DL, et al. Analgesic Rebound Headache in Clinical Practice: Data From a Physician Survey. The Journal of Head and Face Pain. 2002;36(1):14-19. 7. Neilsen KD, Rasmussen C, Russell MB. The diagnostic headache diary- a headache expert system. Stud Health Technol Inform. 2000;78:149-160. 8. Silberstein, SD. Sex Hormones and headache. Rev Neurol. 2000;156: 4S30-41.9. Jull G, Trott PH, Potter H, et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835-1843. 10. Hammill JM, Cook TM, Rosecrance JC. Effectiveness of a Physical Therapy Regimen in the Treatment of Tension-Type Headache. Headache: The Journal of Head and Face Pain. 2002;36(3):149-153. 11. Watson DH, Trott PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia. 2002;13(4):272-284.
Cause: Unknown, may involve change in the blood vessels of the brain. Duration: 4-72 hours long. Frequency: Daily to once every few months. . Characteristics: Much more common in females than males. Pain often described as throbbing (pulsating) on one side of the head that may spread. Complaints of nausea, vomiting, sensitivity to light and sound are common. Aggravating factors: Headache may be triggered by routine physical activity, loud noises, strong smells, stress, certain foods and alcohol. Treatment: Over-the-counter pain anti-inflammatory drugs (ibuprofen), prescription pain medication, and preventive medications. Avoidance of triggering events can also decrease number of migraines experienced.
Type 2: Migraine with aura (warning signs) Cause: Unknown, may involve change in the blood vessels of the brain. Duration: 4-72 hours long with "aura" prior to onset. Frequency: Daily to once every few months Characteristics: Much more common in females than males. Hours before onset of pain, many experience feelings of elation, drowsiness, depression, hunger, or thirsty. Just prior to the headache odd sensations are experienced such as seeing flashes of light and blind spots in vision, dizziness, and numbness in the body. These experiences are referred to as an aura, which occurs just prior to pain onset. Pain often described as throbbing (pulsating) on one side of the head that may spread. Complaints of nausea, auras, sensitivity to light and sound are common. Treatment: Over-the-counter pain anti-inflammatory drugs (ibuprofen), prescription pain medication, and preventive medications. Avoidance of triggering events can also decrease number of migraines experienced. Cluster Headache: Cause: May involve vasodilatation (widening) of external carotid artery. May be associated with sleep disorders, sleep deprivation, or decreased testosterone (male sex hormone). Duration: 15-180 minutes Frequency: Headaches may be daily during certain periods of the year, often a few times a year. Characteristics: Much more common in males than females. Severe pain on one side of the head. Eye and nasal problems on side of head often experienced. Many report that pain happens at predicable times during day. Pain may be so severe that sufferers may pace and hit head on walls. Treatment: Education that although pain is very severe it is not a serious medical problem. Medications and avoidance of aggravating factors (alcohol, certain foods) can be beneficial.
Tension Headache: 80% of all headaches experienced Cause: Unknown, may be a combination of muscle contraction problems and psychological distress. Duration: 30 minutes to 7 days Frequency: Up to 15 times a month. Characteristics: Most report feeling pain on both sides of head that is dull and persistent. Commonly people report feeling pressure, heaviness, and tightness throughout the head. Anxiety and depression may also be present in many people who experience tension headaches. Treatment: Pain relievers, relaxation exercises, stress management, and physical therapy are commonly helpful. Mechanical pain: Pain that is increased or decreased by movement and positions (posture). Pain is a result of strain on the muscles, ligaments and joints of the neck. Rebound Headache: A type of headache that results from your body becoming reliant on pain medication. Supervised withdrawal from the medication with evaluation of symptoms is the treatment.
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