Tamer S. Issa, PT, BSc, DPT
Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT
Abstract: Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial,
articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.
Key Words: Chronic Daily Headache, Physical Therapy, Diagnosis, Management, Orthopaedic
Manual Physical Therapy, Dry Needling, Myofascial Trigger Points
Headaches are one of the most common reasons why people seek medical attention. They constitute the leading cause for neurology visits, accounting for one-third of outpatient visits1. No data are available discussing the prevalence of headache as a cause for orthopaedic physical therapy visits; however, Boissonnault2 reported headache as a co-morbidity in 22% of patients presenting for outpatient physical and occupational therapy services. Most relevant to the physical therapist are those headaches that to some extent have (or may have) a neuromusculoskeletal etiology, as those are the headache types that could logically be expected to benefit from physical therapy (PT) diagnosis and management. The International Headache Society (IHS) has long aimed to improve upon the understanding, diagnosis, and management of headache disorders. The IHS published the first internationally accepted and clinically useful headache classification system in 1988 with the first edition of the International Classification of Headache Disorders (ICHD); a second edition (ICHD-II) was published in 20043. The ICHD-II has classified hundreds of different types of headaches within two categories: primary headaches and secondary headaches. Primary headaches are the most common headache types and have no other underlying cause. They include migraine headache (MH), tension-type headache (TTH), cluster headache and additional trigeminal autonomic cephalalgias, and other primary headaches. Secondary headaches are classified according to their causes and are classified in 10 separate categories. Of the primary headaches, there is mounting evidence in the scientific literature that TTH and—to a lesser extent MH—may have an underlying neuromusculoskeletal contribution. Secondary headaches with a neuromusculoskeletal etiology include cervicogenic headache (CGH), occipital neuralgia (ON), and headache associated with temporomandibular disorder (TMD).
TTH is the most common yet least studied of the primary headaches4,5. It was once thought to be primarily psychogenic, but now there is evidence of a neurobiological component. Recent studies aimed at understanding the etiology and mechanism of TTH have looked at the role of muscle contraction, the significance of pericranial muscle tenderness, and the combined influence of these peripheral inputs with central etiologic features6,7. The most well-documented abnormality found in TTH is pericranial muscle tenderness6-8. It has been proposed that in patients with chronic TTH, prolonged nociceptive stimuli from pericranial myofascial tissue contribute to supraspinal facilitation leading to central sensitization, which in turn results in an increased general pain sensitivity6,7,9. Central sensitization arises from the amplification of receptiveness of central pain-signaling neurons to input from low-threshold mechanoreceptors and is clinically characterized by the presence of hyperalgesia and/or allodynia10,11. Table 1 lists the ICHD-II diagnostic criteria for some of the TTH forms.
It has been hypothesized that part of the continued peripheral nociceptive input leading to central sensitization in patients with TTH originates in myofascial trigger points (MFTrPs). Referred pain originating in these MFTrPs may also contribute to the clinical presentation of patients with TTH12-15. A MFTrP is defined as a hypersensitive nodule within a taut band in skeletal muscle, which is painful on compression and which may cause characteristic referred pain, tenderness, or autonomic phenomena12-14,16-18. Myofascial trigger points can be found in a specific muscle or group of muscles and can limit the flexibility of the affected muscles12. Active MFTrPs cause clinical symptoms of pain and restricted motion, whereas latent trigger points may not contribute to pain but still influence muscle fatigue and mobility12-14,16-19. Several muscles of the head and neck have referral pain patterns into the head that can cause or contribute to pain distribution patterns commonly associated not only with TTH but also with MH and secondary headaches such as CGH, occipital neuralgia, and TMD. Other trigger point–related symptoms may include tinnitus, eye symptoms, and torticollis12-21.
MH is a common disabling headache with a strong genetic basis. This headache type can be divided in two categories: migraine with or without aura (Table 1). The pathophysiology of MH is believed to be a neurovascular disorder of the trigeminovascular system in which a dysfunctional vasodilation in the brainstem mechanically irritates sensory fibers of the trigeminal nerve resulting in the release of inflammatory substances and the activation of meningeal nociceptors. Release of substance P and calcitonin gene-related peptide further contributes to vasodilation and neurogenic inflammation leading to an increased activation of neurons in the trigeminal ganglion and subsequent transmission of pain signals to the brain. During the progression of an MH episode, the spinal and supraspinal nervous centers become sensitized resulting in increased pain and sensitivity to stimuli22.
The proposed etiology of CGH is based on the convergence of afferent sensory input into the cervicotrigeminal nucleus from structures that are innervated by the first three spinal nerves or the trigeminal nerve. A subsequent “misinterpretation” of nociceptive signals originating in the cervical somatosensory structures as coming from the structures in the head innervated by the trigeminal nerve is thought to be responsible for this type of headache23-27. Musculoskeletal structures in the neck that are innervated by the first three spinal nerves that may refer pain into the head include the atlanto-occipital joints, joints and ligaments of the atlanto-axial joint, the C2-C4 zygapophyseal joints, the C2-C3 intervertebral disk, and muscles innervated by C1-C323-29. Table 2 lists the diagnostic criteria for CGH.
Temporomandibular disorder describes a variety of conditions affecting the temporomandibular joint (TMJ) and the muscles of mastication30. Symptoms include jaw and facial pain, limited TMJ mobility, joint sounds, tinnitus, and—most relevant to this case report—headaches15,16,30,31. A classification of TMD into two subtypes provides a better understanding of the disorder and possible treatment options30. Arthralgia encompasses impairments related to the joint biomechanics, internal derangements, degenerative changes, developmental defects, and other pathologies related to the TMJ30. Myalgia is related to impairments and pain in the musculature surrounding the TMJ30. Table 2 lists the diagnostic criteria for TMD-related headache.
Data on the epidemiology of headache further underscore the need for knowledge related to headache. We noted that headaches are one of the most common reasons for people to seek medical attention. Headaches are more prevalent in women than in men but preva- lence tends to decrease with age1,32,33. Up to one adult in twenty has a headache every day or nearly every day1. Most of the population studies and research have focused on MH: European and American studies have showed the prevalence of MH as 6-8% in males and 15-18% of females each year1. One in four American households has a migraine sufferer, totaling approximately 29.5 million people32. TTH is even more prevalent: it affects two-thirds of males and over 80% of females in developed countries1. Episodic TTH is the most common headache type reported in over 70% of some populations; chronic TTH is found in 1-3%1. Approximately 78% of adults will suffer from a TTH at least once in their lives32. The prevalence of CGH has been reported to be 0.4% to 2.5% in the general population and as high as 15% to 20% in those with chronic headaches23. The prevalence of TMD in the Western population ranges from 10% to 40%15. TMD can be episodic, but it is often a chronic condition affecting women more than men15 and can be associated with headaches. Medication-overuse headache is a chronic headache form that affects up to 5% of the population1. Chronic daily headache is perhaps the most disabling of the headache groups. It signifies those who experience a headache daily, or nearly daily (15 days or more per month), and affects up to one in 20 adults worldwide1.
Headache also has a significant socio-economic impact. Persons with chronic headaches report disabling complaints that interfere with daily activities. Work capacity and social activity is reduced in 60% of TTH patients and in almost all of MH patients33. A 2001 report by the World Health Organization (WHO) stated that MH contributed to 1.4% of all years lived with disability (YLDs), ranking it as the 19th highest cause of disability in both sexes of all ages33. Among women, it contributed to 2.0% of YLDs, which ranked it 12th among causes of disability33. The financial impact of headaches on the sufferer and society is of considerable concern. Healthcare costs are 70% higher in families with migraine sufferers in the United States34. Outpatient healthcare costs in the US were 80% higher for “migraine families” than for “non-migraine families”34. Pharmacy costs accounted for 20% of total healthcare costs in migraine families, compared to 15% in non-migraine families34. The prevalence of MH is highest between the ages of 25 to 55 years, corresponding to an individual’s most productive years34. In the United Kingdom, some 25 million working days or school days are lost every year because of MH1. It has been reported that 8.3% of patients with episodic TTH lost an average of 8.9 work days and that 11.8% of patients with chronic TTH lost an average of 27.4 work days35.
Headache can be difficult to evaluate, and an individual may present with multiple forms of the condition. As indicated above and in Tables 1 and 2, TTH, MH, CGH, and TMD share many similar signs and symptoms. Muscle tenderness to palpation is a common finding among them, making it difficult to differentiate between them. To further complicate matters with regard to differential diagnosis, some authors believe that MH and TTH are in fact headaches on the same continuum, while others believe they are separate entities3,6. There is also overlap between various headaches and TMJ pain, as the head and face share a common innervation and vascular supply leading to similar pain patterns in case of dysfunction or disease30. There is a close relationship between the increase of bruxism (grinding or clenching of teeth) and parafunction (excessive or unnecessary function related to the jaw) found in TMD and an increase in TTH frequency30. One review looked at the CGH diagnostic criteria and concluded that there was insufficient specificity to separate CGH from MH patients36. Another study looked at the association between MH and TMD and concluded that they were two clearly differentiated diagnostic entities30. Various authors agree that there are neuromusculoskeletal abnormalities that play a role in the pathogenesis and presentation of TTH6-8,12-16,20,24-26,37, 38, MH26,37,38, CGH16,24-26,28-30,37,38, TMD-related headaches15,16,30,31,38, and occipital neuralgia headaches21 further exacerbating the difficulty faced by the clinician with regard to differential diagnosis16,21.
Despite the high prevalence of headache disorders and their socio-economic and personal impact, headache disorders continue to be underestimated in scale, poorly diagnosed, and undertreated by the medical community1,33. The patient described in this case report presented with a medical diagnosis of MH and chronic TTH with an onset of a new type of chronic daily headache potentially related to a history of motor vehicle accident (MVA) and/or possibly caused by TMD. The etiology of various headaches is often hard to determine with potential combined influences of neurological, musculoskeletal, neurovascular, psychological, and nutritional factors and chemical imbalances in the brain. Some headaches are indicative of an underlying disease process; some of these are life-threatening and others benign. Thus, a thorough medical evaluation is necessary with any new onset or ongoing headache. Likewise, a thorough PT examination should aim to rule out serious pathology by way of a systems review approach, to determine the type of headache, and to define the neuromusculoskeletal factors that may be contributing to the headache. An accurate differential diagnosis is imperative in determining whether a headache is neuromusculoskeletal in origin, which is treatable, or whether it is another type of headache that requires medical consultation and (co) management. The purposes of this case report describing a patient with chronic daily headache are to:
- Describe the PT differential diagnosis and decision-making process
- Provide a treatment rationale and description of subsequent PT management using a combination of myofascial trigger point dry needling, orthopaedic manual physical therapy (OMPT), exercise therapy, and patient education.