Case commentary - Headaches
Case commentary – Headaches
Though few people would look to physiotherapy as a treatment for those who have chronic headache and migraine problems, experience has shown that when the correct management plan is implemented many people’s problems can be significantly improved, if not cured.
A lot of headaches are myo-fascial (muscles and connective tissues) in origin. Tight muscles can pull on the neck and the base of the skull causing aches and pains, and the formation of trigger points (extremely tight, spasmed or contracted muscle) can refer pain directly to many different areas of the head ranging from the eyes, cheeks, and jaw to the back of the head, the ears and all that is in between.
Two examples will be discussed below.
Case 1
Constant band of pain:
This 33-year-old man presented with chronic headache symptoms that took the form of an almost constant band of pain around the top of his head.
The symptoms had been present for several years and had been exacerbated following a fall in which the client injured his neck.
Over the years in which the problem had been present the patient had undergone brain scans, MRI scans, CT scans and various other investigations without any definitive findings and had been prescribed numerous medications without significant improvement.
On initial assessment the patient presented with what he described as a band of pain around his head and explained how it was almost constantly there. Further questioning revealed that he had not always suffered from the headaches and that he found they did tend to be worse in the morning, after sitting reading/writing at a computer for prolonged periods, and when he felt tense or under stress.
When examined it was clear to see that there was definite involvement of the neck and surrounding muscles and connective tissue. Although range of movement was essentially full and without pain, the muscles were extremely tight, with numerous spasms, and were very painful on palpation. Additional investigation revealed several 'triggers' in the soft tissues which reproduced the headache symptoms experienced by the patient.
Over the next 4-5 sessions we worked on reducing the spasm and tightness in the muscles and releasing the triggers with deep soft tissue manipulation, joint manipulation (to ensure the joints of the neck and back could move freely and effectively) and some stretching work. A significant improvement was felt from the initial treatment session and the duration of the improvement increased with each subsequent treatment. Once the symptoms had settled we implemented some strength and conditioning work to support the muscles of the neck, allowing them to deal effectively with the clients day to day rigours without becoming overworked and tight, consequently developing more trigger points.
After a follow up 3 weeks later the client was delighted to report that he had hardly any awareness of his old pain at all and, allied to the occasional maintenance session every now and again, his symptoms have remained settled and manageable.
Case 2
Stiffness & morning headaches:
A 41-year-old solicitor who spent most of her time at her desk presented with constant trouble in the form of pain and tightness across the back of her shoulders and neck when she woke in the morning (lasting for several hours or slightly less if she took analgesics), and after a long day at work.
She had previously had similar problems on and off for the past 18 months or so with no particular incident of injury she could recall that may have precipitated the problem.
Further questioning also brought to light a right-sided headache alongside the other symptoms of stiffness and pain in the mornings, although she hadn't realised that the two complaints were potentially connected.
On examination range of movement of the neck and shoulders was within normal limits with some stiffness noted in the inter-vertebral movements, but no other obvious restrictions. However, palpation of the soft tissues elicited significant tenderness and identified several triggers producing the headache symptoms, not all of which were directly around the neck – some were as distant as her shoulder blade.
Treatment consisted initially of deep soft tissue manipulation and release work (to alleviate spasm and contractures in the muscle and eliminate the triggers), neck and thoracic spine manipulation (to facilitate improved spinal mechanics) and some home-based stretching and mobility work (to maintain the gains from treatment sessions). After 3 sessions the frequency of the headaches had reduced from daily to once or twice per week and with 2 additional treatments they had settled entirely, with the stiffness in the morning also greatly reduced.
Following the prescription of some strengthening exercises, some ergonomic advice on how best to arrange her workstation, and the elimination of some bad telephone habits the headaches, pain and stiffness that were once so frustrating are no longer an irritant.
