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Cranial Made Clinical:Headache Symposium

Part 2: Muscle Tension Headache

Kate Worden, DO, MS

Clinical Professor OMM

MWU AZCOM

AOMA Spring Convention

13 April 20191

Disclosure

• I have no financial or other disclosures to make regarding this presentation

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Learning Objectives:

• Be able to contrast the common clinical presentations of 4 distinct headache types:– Migraine Cephalgia

– Post Concussion Cephalgia

– Cervicogenic (Muscle Tension) Cephalgia

– Temporo-Mandibular Joint (TMJ) Dysfunction

• Using the Headache Algorithm identify the appropriate diagnostic work up & Tx for: – Cervicogenic/Muscle Tension Cephalgia

– Migraine Cephalgia

– Post Concussion Cephalgia3

Learning Objectives:

• Demonstrate a knowledge of the underlying mechanisms of these headache types.

• Identify which somatic dysfunctions are commonly found in each type of headache.

• Identify the Indications and Contraindications for Osteopathic Manipulative Treatment for the above headache types.

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Learning Objectives:Understand the importance of Restoring Autonomic Nervous System Balance in the Cervical & Thoraco-Lumbar Spine:

• SNS: • Trigeminal Nerve (CN5)-caudate nucleus to C1,C2, C3

• Sympathetic chain ganglia: – Cervical: upper, middle, lower

– Thoraco-Lumbar: T1-L2

• PNS: Vagus N (CN X) influence via :

– Compression of CN X at Upper C complex/Foramen magnum

– Entrapment of CN X within Occipital Mastoid Suture as it traverses the Jugular Foramen

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Learning Objectives (LAB):

Be able to perform the following techniques:

• Strain Counterstrain (SCS) to tenderpoints:– Posterior C1

– Anterior C1

• Still Technique to OA Joint (C0-C1)

• V-spread to the Occipito-Mastoid (OM) suture

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Case Presentation:

• 26 y/o Asian Female, Osteopathic Medical Student

• C/o gradual onset of neck stiffness, sore shoulder muscles & now almost daily headaches for 3 mo.

• 2 types: Start at base of skull then curve forward to forehead and behind the Right eye (Ram’s horn) OR, bilateral temples and pressure at bridge of nose

• Better for a short time with yoga & massage, some temporary relief with Aleve ii bid. Worse with prolonged studying & computer usage

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What Does a Headache Look Like?

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BilateralTemples

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Vertex & Nose Bridge

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Whole Head

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Base of the Neck

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Forehead

Behind the Eye

Kids get Headaches Too!

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The eyes are the window to the soul…

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What Brings on a Headache?

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Headaches & Life Stressors

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Headaches and Emotions

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Work Stress, Computers & Headaches

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Headaches & Prolonged Studying

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Headaches and Sleep Position

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Headaches & Weather Changes:

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Headaches and Headgear

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Myofascial Trigger Points & Headaches

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SCMTRAPS

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Biomechanics of Posture

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Straightened or even reversed C curve esp from hypertonic Scalenes & SCM-Leads to head forward posture.

Headaches vs Low Back Pain

• Low Back Pain is the #1 reason patients seek medical help

• BUT

• Headache is the #1 reason people miss work !

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Cervicogenic Headache: DefinitionRecommended term vs Muscle Tension Headache

• Pain referred to head from musculoskeletal dysf of Cervical region & related areas– Etiology: Som Dysf w muscle spasm, decreased ROM,

tenderness, worse w movement, better w rest

– Assoc. w C muscle tendonitis, triggerpoints (TP), tenderpoints (tp), in head +/or neck, & C Jt. Inflam

– Pain relieved by successful Tx of SD once r/o systemic or local head region pathology as cause

• See Cervicogenic HA International Study Group for diagnostic criteria

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Cervicogenic Cephalgia: Sx

• Suboccip radiates to vertex or retro orbital

• Usu bilat, vice like tightness+/-photophobia & nausea, may be throbbing or pounding

• Trigeminally mediated pain-arises from a combo of spinal facilitation & referred pain patterns- typical Ram’s Horn distribution

• Rarely unilat & no prodrome/aura

(vs Migraine usu unilat & often have aura)28

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Dx Criteria from International HA Society:

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Cervicogenic HA: Natural Hx

• Lack regular pattern

• Quality of life affected-loss physical functioning

• Recurrent, episodic, last hrs to days

• Whiplash injury can lead to chronic Cervicogenic HA

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Inertial Injury

Diffuse Axonal Traction Injury:

Bone & Soft Tissue Injury

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Post Whiplash SyndromeInertial Injuries

*Head rotated at impact*

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Extends then Flexes*

Cervicogenic HA: Differential Dx (DDX)

• Migraine

• Occipital neuralgia

• Muscle Tension-type HA

• TMJ Dysfunction• Causes of Head Pain from other Cervical pathology:

– Trauma

– Herniated Disc

– Spondylosis (OsteoArthritis)

– RA34

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DDX cont.

• AV Malformations

• Cerebral Aneurysm

• Chiari Malformations

• Pseudotumor cerebri

• Vasculitis

• Vertebral Artery Dissection

• Glaucoma

• Meningitis

• Posterior Fossa Tumor

• Hemorrhage– Subdural

– Subarachnoid-Thunderclap HA

– Epidural

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HA Algorithm

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Functional Anatomy:

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All parts can generate pain

Autonomic(ANS) Influences of C spine

• Sympathetic(SNS): sup, middle & inf chain ganglia– C1-C4 Cervical Plexus-Cervico-Cranial Syndrome esp

via Trigeminal (CN V)– C5-T1 Brachial Plexus-Cervico-Brachial Syndrome– T1-T4 provide SNS to Head & Neck

• Parasympathetic(PNS):– CranioSacral System esp via Vagus (CN X)

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Key Muscles:

• Suboccipitals- level the occiput & temporals to horizon to ensure optimal fxn visual & vestibular systems

• Levator scapula-attaches T spine, UE, neck(not head)-causes “stiff neck”

• Trapezius - attaches T spine, UE, neck & HEAD-causes “Ram’s Horn” HA

• SCM: attaches sternum & med clavicle to mastoid pr of temporals-SB to & Rotate away from affected muscle-leads to head tilt to SideBent side

• Scalenes: attach R1 & R2 to neck-lead to forward head posture

• Semispinalis, Splenius capitis, Longissimus capitis-connect head & neck to T spine

• Anterior Cervical Flexors: Longus coli, Longus capitis-like psoas (hip flexor) in the neck 39

Suboccipital Muscles:Rectus capitis posterior

major

minor

Obliquus capitis

superior

inferior

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LEVATOR SCAPULA & SPLENIUS CERVICIS

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Neck mm attach as low as T4!

Trapezius

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SCM –2 Different Pain Patterns:

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Sternal Head (AC8) Clavicular head (AC7)

Scalenes and Longus coli & capitis

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Longus coli m of the ant neck-like the Psoas m of the ant hip!

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Fascial Triggers:

• Nuchal Ligament: can actually limit neck flexion

• Myo-dural Bridge: formed by suboccipital mm & their tendons & perivascular fascial sheaths– Muscles fuse directly w spinal dural from C1-C3!

– Forms the tender Atlanto-Occipital membrane (Ant & Post)

• C spinal dura:

– innervated by sensory n.

– responsive to stretch

– potential mechanism for pain in post occipital area after a strain or prolonged contraction

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Contributory Nerves:

• CNS:– Tectospinal tract coordinates eye & neck

movements• Oculo-cephalic reflex-can use eye muscles to

move small neck muscles for Muscle Energy

– Vestibular fxn (balance & equilibrium)-• linked to neck motion

– Neck motion-• linked w Shoulder & Upper Back motion

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Contributory Nerves: Cranial Nerves

– Trigeminal (CN V)• Som dysf of C spine refers

pain to head & face via CN V

• innervates cranial & facial structures, incl. cerebral blood vessels, dura mater

– Trigeminal Nucleus Caudalis (TNC)

• descends as low as C4-contiguous w the grey matter in the spinal cord dorsal horn

• converge w Sensory n’s from Upper C (C1-C3) -

Thus: pain signals from neck can be referred to head & face

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Contributory Nerves:

• Lower C (C5-C7): nociceptors can refer pain to head & face via TNC because info can ascend 1-3 levels before entering dorsal horn

• Bottom Line: nociceptors from Cervical structures can be perceived as head pain in regions where Trigeminal (CN V) innervates: occipital, temporal, frontal, facial areas*

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Contributory Nerves:

• Vagus (CN X): – ganglia lie below the foramen magnum

Mixed nerve w motor, sensory & PNS

– Nociceptors & inflam stimuli from the larynx, pharynx, thoracic & abdominal viscera are transmitted by Vagus to Upper Cervical afferents

– this can lead to efferent discharge of C spinal motor n,

– accounts for palpable incr in myofascial tissue tension in Upper C spine (ie, viscerosomatic reflex)

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Contributory Nerves:

• Primary sensory axons from sup. vagal gangli terminate in TNC carrying sensation from EAM (ear canal), ext TM (eardrum), and skin of the ear to the TNC

• Myofascial Restriction of the Jugular foramen thru Occip-Mastoid Suture (OM) affects CN IX, X, XI

• Spinal Acces N (CN XI): – sends motor to SCM & Trapezius

– some afferents to TNC to produce pain

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Vagus (PNS) & Trigeminal(SNS) lie adjacent at upper C complex:

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Note:

1. How far inferiorthe nuclei of CNs V & X go below Foramen magnum

2. How close they are together!

Contributory Nerves:

• SNS:– SNS fibers dense in dura mater at Occipital base

– SNS afferents from skin (vaso-, sudo- & pilo-motor)

– C SNS ganglia (sup, mid, inf)-Sup C ganglion, ANT to C articular pillar of C2 vert. -innervate vasculature & mucous membrane of head

– T1-T4 spinal n send SNS preganglionic fibers to head

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Contributory Nerves: Peripheral Nerves:

• C1-C3: form Greater & Lesser Occip Ns -innervate post scalp-entrapment can lead to Occipital Neuralgia– C1 n innervates OA Jt. -can refer pain from SD to the Occipital region

– C2 n-innervate AA Jt & C2 & C3Jts. SD refers deep dull pain from occip to parietal, temporal, frontal & periorbital, w paroxsysmal sharp pain superimposed (C2 Neuralgia)

– C3 n -innervates C2 & C3 Jts. SD often in whiplash injury transmits referred pain to fronto-temp and periorbital regions

– C4 n-innervates midscapular & shawl of shoulder areas

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Cervical Nerves to the Head:

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Upper Cervical Nerve Patterns:

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Inflammatory Markers:

• Pro-Inflammatory cytokines are higher in Pt w Cervicogenic HA than Pt. with migraine– Interleukin (IL-1)

– Tumor Necrosis Factor (TNF)

– Nitrous Oxide (NO)

• Calcitonin Gene Related Peptide (CGRP) is present in Pt. with Migraine HA but not in Pt. with Cervicogenic HA

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Key to tell Cervicogenic from Migraine HA:

Migraine HA:

• Nausea + Vomiting

• Too severe to sleep

• +/- Aura

• IL-1, TNF (low)

• NO (low)

• CGRP (+)

Cervicogenic HA:

• Nausea but NO Vomiting

• Able to sleep

• No aura

• IL-1, TNF (high)

• NO (high)

• CGRP (-)

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Levels of Medical Evidence:

A = Highest– Randomized Controlled

Trials

– Meta-Analyses

– Systematic Reviews-well designed

B = Medium– Case Controlled or Cohort

Studies

– Retrospective Studies

– Uncontrolled Studies

C = Least – Consensus Statement

– Expert Guidelines

– Usual Practice

– Opinion

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Level A Evidence for C manipulation:INDICATIONS for OMT: in Acute, Subacute & Chronic

Neck Pain and Headache

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Benefits of OMT for Cervicogenic HA:

• Decreased Pain -frequency, intensity & duration

(Level A Evidence)

• Improved functionality -in Activities of Daily Living (ADL) & work productivity

• Decreased reliance on analgesic & other medications-can have side effects & complications

• Less need for more invasive procedures- (Triggerpointor Botox injections, Nerve blocks, Steroid epidural injections, Radiofrequency Ablation or Surgery)

(Level A Evidence: randomized controlled trials, meta-analyses & systemic reviews)62

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Contraindications to OMT:

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Cervicogenic CephalgiaWhere to focus your OMT:

• Jt: OA, AA, C2, C4-C5, C7, T1, T4

• Muscles: – Traps, SCM, scalenes, suboccipitals

– Reflex to M. of Mastication-clenching, bruxism

– SCS tenderpoints

• Fascia: Cervical & Upper Thoracic

• Cranial: compression of: SBS, Occ condyles, Occipital-Mastoid suture

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Typical Sequence for Tx Cervicogenic HA:

• Seated– Necklace technique (MFR) to Thoracic outlet & C-T fascia (LYMPH)

– ME or Still to TLJ & T4-T1

– Still to R1, R2, Sternoclavicular Jt. using UE

• Supine– MFR to Cervicals: bowstring +/-squeeze toothpaste tx for (LYMPH)

– Indirect Rib raising from above: to T1-T4 (SNS)

– SCS: to key muscles (Traps + SCM, Lscap, Scalenes, ant & post Cs)

– ME or Still: to remaining Cervical Jt dysfunctions

– Suboccipital Release, BLT, ME, Still or HVLA: to OA (SNS & PNS)

• Cranial– Venous Sinus Drainage with Occ condylar decompression

– CV4 & V-spread the Occipito-Mastoid suture 65

Other Structures above are: Facilitated Structures

Case Presentation: CC:

• 26 y/o Asian Female, Osteopathic Medical Student

• CC: neck stiffness, sore shoulder muscles & now almost daily headaches

• 2 types: – Start at base of skull then curve forward to forehead and

behind the Right eye (Ram’s horn) OR, – Bilateral temples and pressure at bridge of nose

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Case Presentation: Hx

• Occasional nausea, but no aura or neuro symptoms

• Intensity: pain range: 0-8/10, 4-5 bad days/week

• Soc Hx: Lots of pressure from family to succeed, Diet: Lots of sugar & caffeine to make up for lack of sleep, No TOB or ETOH.

Denies depression but often worried re failure

• Previous Injuries: As a kid ran into glass door, hit nose & R forehead, stitches but no LOC or Fx(significance-predict what cranial findings?)

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Case Presentation: PE

Vitals: 110/65, 85, 14, 5’4”, 140#, 98.2 F

– Gen: mild distress w pain facies, holding R forehead

– Mental Status: A & O x 3, Affect blunted (signif?)

– Neuro: CN I-XII intact, Sensation Intact (LT), Strength (5/5), DTR (+2/4 sym)

– HEENT: decr ROM but no rigidity, no discharge

– CV: HRR w/ occ ectopy (why?)

– Lungs: clear to auscultation

– GI: BS x 4 w/o mass, tender or HSM (hepatosplenomegaly)68

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Case Presentation: PE

• Screening Osteo/MSK Exam:– C: increased lordosis w/ marked decr Flexion & SB Left,

Rot Bilat. (which mm’s tight?)

– T: upper & lower incr kyphosis, mid-flattened (signif?)

– L: lower incr lordosis Sacrum: rigid w L/S compression

– Pelvis: L post innom rotation

– Rib: R1-2 inhaled Right (which m tight?)

– Abd/Visc: breath shallow, Celiac & Sup Mes ganglia + (signif?)

– UE: hunched rounded shoulders, tense R forearm mm– LE: SLR (-) w/ tight hamstrings, psoas & weak abds

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Case Presentation: PE

• Cranial: CRI: Rate 10, Amplitude low, Flexion, R torsion, R Temporal IR w/ R occ-mastoid suture compression, Venous sinus congestion, Frontal compression, jaw deviates R with opening click (signif?)

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Case Presentation: Clinical Reasoning

• Where does this HA fit on the HA Algorithm?

• What clues are found in the Hx & PE?

• Where is the Area of Greatest Restriction (AGR)?

• How will I sequence the OMT Tx for this patient (Where do I start & where do I go next & why)?

• How might remote dysfunctions play a role in maintaining this headache pattern?

• What Exercises can I teach this patient to begin to change her postural imbalance?

• What lifestyle counseling does she need? 71

Case Presentation: ASSESSMENT & PLAN

ASSESSMENT:

• Headache:– Cervicogenic (ICD10: G43.909)

– Consider TMJ, Migraine

• Atypical Facial Pain (650.1)

• Anxiety, situational

• Somatic Dysfunction:– H, C, T, R, UE

PLAN:

• OMT to 5 areas– Regions: H, C, T, R, UE

– Using: ME, MFR, SCS, Cranial

– Response to OMT?

• Rx?

• Diagnostic Testing?– Labs or Imaging

• Teach Home Exercise

• Lifestyle Counseling

• Recheck72

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LAB

SCS to C1-posterior (PC1Reg) and anterior (A1C)

Still technique to OA

V-spread the Occipito-Mastoid Suture

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Headache Lab: Cervicogenic Headache > TREATMENT SEQUENCING

Palpate for Muscle Tension 

Suboccipital area:• Rectus capitis posterior major & minor (PC1R)• Obliquus capitis • Occipital Condyle • Occipital Mastoid Suture

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Principles of Strain Counterstrain (SCS):

• Find a tenderpoint with testing pressure

• Put the associated muscle, fascia, etc. in its most relaxed position, wrapping around the opp. side and hold for 90 sec

• 3 phases of release:– Nerve phase: pain diminishes- then use monitoring pressure (less)

– Circulatory phase: as fascia relaxes, the relatively ischemic area allows fresh blood to enter-feel a pulse

– Lymphatic phase: as fluid passes through the capillary, the lymphatics drain-feel a softening

• Slowly, passively return body to a neutral position

• Retest. Goal is 70+% improvement

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Cervical

SCS of suboccipital muscles: Posterior C 1 Regular (P1C):

Anatomic Correlation:  Rectus capitis posterior major/minor, Obliquus capitis superior & Post Occipto‐Atlantal membrane

Clinical Correlations:  Headache on the ipsilateral side of the head

Location:  On the occiput lateral to the main posterior cervical muscle mass 1 ½ inches from midline. Pressure is applied posterior to anterior directing the force slightly cephalad. 

Technique:Patient: SupinePhysician: Seated at head of table1. Extension at level of C1: Hyperflex the cervicals to then allow 

marked extension of C1 on the occiput. 2. Sidebend away slightly, and Rotate away slightly from side of TP. 

Technique 1

P1C Regular SCS treatment position

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Technique 2

Cervical

SCS of suboccipital muscles: Cervical ANTERIOR C1 (A1C):

Anatomic Correlation:  Rectus capitis anterior & fascia of the anterior Occipito‐Atlantal membrane

Clinical Correlations:  Mimics TMJ pain, frontal headache, neck pain.

Location:  The Posterior surface of ascending ramus of mandible ½ ‐ ¾ inch above angle of the mandible. Pressure is applied posterior to anterior on ramus of the mandible. 

Technique:Patient: SupinePhysician: Seated at head of table1. Side bend away from the TP slightly, and rotate away 

markedly from the side of the TP. No flexion or extension.

SCS A1C treatment position 

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Principles of Still Technique

• Make a Dx, eg C2 FRS R

• Indirect: Take the dysfunction to its most relaxed position eg flexed, rotated and sidebent right.

• Activate: Add slow steady compression (or distraction) until the dysfunction softens

• Direct: Take the dysfunction toward the barrier in all 3 planes, eg sidebend right, rotate right then extend.

• Recheck. May repeat 2-3x if needed

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Technique 3

Cervical:  

Supine Still Technique of the OA:

Diagnosis: OA FSRRL

Technique: Patient: Lying SupinePhysician: At head w/ both hands on occiput in neutral.1. Flex & add SB (to R) by transla on (from R→ L).2. Add ROT to point of ease (L)3. Compress using both hands –just enough to hold position of 

localization.4. Maintaining compression, slowly                                             

take head toward barrier in each plane:• SB to (L)• ROT to (R)• Extend

5. Can repeat as needed6. RECHECK!

Figure  1a‐b. Hand position for Still OA Supine 

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Tx 4: V-Spread Technique

• Fluid Technique-– We will use to release a fluid/fascial restriction of the

Occipito-Mastoid (OM) Suture

• Find the longest diagonal in the head from the restricted suture and send a fluid impulse until it softens.

• Activating force = The Potency of the Primary Respiratory Mechanism (PRM)/Cranial tide via a fluid wave

• Can use anywhere in the body on any restricted suture, quadrant of the head, SI joint, or element.

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Dx Occipito-Mastoid (OM) Suture Compression

Compression of Cranial Nerves IX, X, XI as they exit the Jugular foramen in the OM suture

• Gently palpate the OM suture

• Using your index or middle fingers on each side

• Assess for: – Edema (fluid in the ditch) or

– Joint restriction (woody, decreased ability to spring)

Tx: V-Spread OM Suture• Place one sensing hand gently over

the restricted suture (or joint) with index & middle finger lying side-by-side abducting to form a small V.

• Find the longest diagonal in the head from this restricted suture.

• With the tips of your finger of the other hand, send a gentle fluid pulse toward the restriction barrier

• After a brief pause, you will sense the wave under the V of your sensing hand. Be aware of the fluid bouncing back.

• Slowly repeat until a softening is felt in the area of the restriction and an impulse no longer sends a fluid wave.

• Recheck over OM suture for less edema (empty ditch) & resiliency of springing.

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V-Spread OM suture

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References:

• Chila, A, Foundations of Osteopathic Medicine, 3rd ed by Lippincott, Williams & Wilkins, 2011, Ch.37: Head and Suboccipital Region by Heinking, KP, Kappler, RE and Ramey, KA, 503 (Pt. Eval), 507-8 (Tension), 508-510 (Migraine), Ch 38: Cervical Region by Heinking, KP, Kappler, RE, 513-527, Ch 60: Cervicogenic HA by R. Hruby, et al, 939-945.

• Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (beta version), Cephalgia, 33 (9) 629–808

International Headache Society 2013. DOI: 10.1177/0333102413485658

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References:

• Meyers, HL, et al, Clinical Application of Counterstrain, TOMF Osteopathic Press, 2006, Ch 1: Treatment of Headache, Neck Pain, and TMJ Dysfunction with Counterstrain by R. Kusunose, 1-38

• Seffinger, M and Hruby, R, Evidence Based Manual Medicine, Saunders Elsevier, 2007,129-187 (Mechanical Neck Pain), 189-205 (Cervicogenic HA), 207-220 (TMJ).

• DiGiovanna, EL and Schiowitz, S, in An Osteopathic Approach to Diagnosis and Treatment, Lippincott Williams & Wilkins, 3rd ed, 2005, 606-607.

• Hruby, RJ, Exploring Osteopathy in the Cranial Field, 2013.

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