Introduction
60% of headaches have their source in the musculo-skeletal system, and in a further 20% of headaches the musculo-skeletal system has a major role to play.
Headaches can be a sign of serious disease. This can be the case where people who have not previously suffered from headaches begin to experience them ; and often the pain is extreme and debilitating.
Be aware of Meningitis, Encephalitis, Cerebral Aneurysms and Brain Tumours. The chances of some one walking into the clinic with any of these conditions is rare, as the pain experienced will usually make the person go straight to A&E. If a person has recently suffered trauma (i.e. in the past 10 days) and has a headache, advise them to go to A&E and get themselves checked out.
Be aware of Hypertension, as that may be the underlying cause of recent onset of headaches. Headaches are also experienced with flu and many viral infections.
A "Thunderclap Headache" is a sudden and excruciating headache of recent onset, and indicates an aneurysmal sub-arachnoid haemorrhage.
The majority of people have headaches of a benign nature, the headaches are not life threatening. These headaches will fall into Tension Type Headaches (TTHA), Migraine (MIG), Sinusitis (SIN),Tempo-Mandibular Pain (TMJ) and Medicine Overuse Headaches (MOH). The Brain does not feel pain. There are no pain receptors in the brain, but there are a lot of very pain sensitive structures around the brain. The Meningeal Membranes and Blood Vessels are very well supplied with pain receptors and are the source of many headaches. Any traction or irritation to these structures will produce pain. Dehydration from Hangover or lack of fluid or any inflammation will cause pain. The Muscles of the Face, Neck and Upper Back can also cause headaches. The site that the pain is experienced can frequently indicate which muscles are causing this pain. When a Muscle develops Trigger Points (TPs) the pain will frequently not be experienced at the site of the TP. The Pain will be referred to a site distant to the TP. When the patient is examined and the TP is pressed, the pain will refer to that site. Trigger points can be agonizing, and people are often in severe pain, unable to function or sleep. When dealt with the pain relief is immense.
Referred Pain
Have you ever had pain in one area and had the niggling feeling that it's "coming from somewhere else"?
Pain is frequently experienced at a site distant to the cause of the pain. It's often the case that the patient is not aware of the site causing the pain until it is pressed and there is a sudden increase in the pain. This is frequently caused by a trigger point or a displaced vertebra. (Referred pain can also be related to disease in an organ. For example, gall stones can cause pain in the right shoulder and kidney stones can cause lower back pain.)
Trigger Points
A trigger point is a taut palpable* band or nodule (knot) found in a muscle. When pressed it will refer pain in a specific pattern to a distant site. It is often the case that trigger points themselves are painless until pressure is applied.
*(Can be felt through touch)
The word migraine is French in origin : Hemi=Half and Crane=Head. This etymology came about, because the Classic Migraine affects half the head.
Classical Migraine (MIG) usually takes the form of self limiting episodes of extreme pain affecting one side of the head, frequently accompanied with nausea, vomiting, photophobia and facial pallor. An attack is usually preceded by a prodromal symptom such as disturbance of vision, tingling and numbness down one side of the body and occasionally disturbance of speech.
Common MIGS are experienced more frequently and often affect both sides of the head, there are no prodromal symptoms.
MIGS are 3 times more common in women than men. This female preponderance would seem to be associated with the vascular changes that occur as a result of the fluctuations in Oestrogen and progesterone. There is an association with menstruation, early pregnancy, the menopause and the OCP.
There is an association with certain foods, chocolate, citrus fruits, Tyramine containing cheeses and alcohol. Alcohol is a non-specific vasodilator. Tyramine causes the release of noradrenaline, which causes vasodilation followed by rebound vasoconstriction. Remember the blood vessels are pain sensitive.
Excess carbohydrate consumption causes a surge and then fall in blood sugar levels, reactive hypoglycaemia can cause MIGS.
The mechanisms that cause MIGS is not completely understood, but there are 3 components:VASCULAR, MYOFASCIAL & EMOTIONAL, which come together to cause a migraine headache. |
Vascular
The prodromal phase is associated with cerebral vasoconstriction. This is when you experience flashing lights, blind spots, slurred speech and numbness. The painful episode is linked to vasodilation of the intra and extra cranial blood vessels. Trigeminal pain receptors in the blood vessel walls, Meningeal Membranes and Venous Sinuses become activated. Vasoactive neuropeptides such as substance P. Neurokinin A and others are released. This causes a neurogenic inflammatory reaction, and the complex pathways followed can be explained by Neuroscience : Basically speaking, an area called the Medullary Dorsal Horn receives these messages, and also the messages from the Myofascial and Emotional components. A summation affect occurs. This information is passed on to the thalamus and then the cortex. Levels of serotonin and catecholamine increase. This is one way that medication works.
Myofascial Component
When the muscles of the head and neck of migraine sufferers are examined, both during and between attacks it is evident that there is widespread tenderness of these muscles. There are also small, discrete focal points of extreme tenderness. When these points are needled (using acupuncture) during MIGS the attack can be aborted, and when needled between attacks, the frequency of MIGS is reduced. The probable reason for this is the pain impulses sent from these points to the Medullary Dorsal Horn is stopped, and the summation affect is not reached. It is also of interest that people who suffer MIGS have low levels beta-endorphin in their plasma and CSF. MIGS may be related to fluctuations of this naturally occurring pain suppressors.
Emotional Component
70% of MIG sufferers consider that emotional upsets play an important part in developing their Headache. Reducing stress plays a vital role in
The Paradigm
According to this model the varying strengths of input to the trigeminal nucleus can cause different types of MIG. When all 3 are strong, a full-blown MIG with aura develops. When the Myofascial & Emotional input are stronger than the Vascular one, MIG without aura develops. When the Vascular component is strong and the other 2 weak, only a MIG aura develops.
Biochemical Changes
Alterations in blood and brain levels of SEROTONIN may influence the development of MIGS. An injection of 0.1% infusion of serotonin into the blood has relieved MIGS. As the peripheral level of serotonin increases, a feed back mechanism lowers the serotonin level within the brain. Also administrating the serotonin releasing agent RESPERINE increases the serotonin levels within the brain and causes a MIG attack, this is aborted by the serotonin receptor blocking agent METHYSERGIDE.
Oestrogen
60% of female MIG sufferers have an increased incidence around the time of their period. And 14% only have MIGS at this time.
This relates to the time of oestrogen deficiency, and it may be necessary to administer oestrogen premenstrually.
Orthodox Medication
Where simple analgesics do not help:
Beta-Blockers (Propanolol & Atenolol) These are the first drugs of choice. There are few S/E. Experimental work shows that these drugs work paradoxically by dilating constricted cerebral vessels while at the same time preventing dilation of the extra-cranial vessels.
Pizotifen (Sanomigran) An Anti-Serotonergic drug & Anti-Histamine. Lowers the levels of brain serotonin. S/E are drowsiness and increased appetite. Serotonin causes the blood vessels within the brain to dilate, and this medication prevents this happening.
Amitryptaline in sub-anti-depressive doses. This acts to alter serotonin levels.
Our Alternatives
Manipulation, Deep Massage, Cranio-Sacral Therapy and Acupuncture can often help.
There are numerous reasons for this. Hands on treatment can affect all the 3 components : Myofascial, Vascular & Emotional.
All of the treatments above will decrease muscle tone and muscle spasm, and deactivate trigger points.
Emotional Component
Massage and specifically Cranio-Sacral Therapy (CST), will deeply relax the patient. CST is great for moving fluids within the cranium, decreasing congestion and pressure.
Vascular Component
This occurs during the attack, and it is doubtful whether hands on treatment will help at this stage. Acupuncture would be the first treatment of choice.
Myofascial Component
On going treatment between attacks, to free up the Myofascial system treat specific muscles and jammed cranial sutures will often, BUT NOT ALWAYS, give a great deal of relief, and may abate attacks completely.
There is probably no one treatment that will prevent Migraine Headaches, but a combination of lifestyle changes; in diet, emotional management, exercise, hydration and maintaining blood sugar levels can be a start.
Medication has side effects, and some of these S/E can be unpleasant : Drowsiness, weight gain, dry mouth, sweats, rashes.
Some people do want to try an alternative, and I have had a fair amount of success treating MIGS.
This type of Headache takes the form of a dull aching sensation or vice-like constriction that usually affects the whole head, but may also be localised to one or other region of it.
On examination muscles in and around the head are found to be tender, commonly the Sterno-Cleido Mastoid, Masseter, Temporalis and Lateral Pterygoid Muscles. Frequently more than one muscle can be involved, and this can present a confusing picture.
There are numerous reasons a person may develop a TTHA. Examples are : sleeping on ones front with the neck extended and rotated, poor posture at a desk with the neck and shoulders forward, bad driving position, vertebral dysfunction in the neck and upper back, (say following a whiplash type injury in a car crash).
Psychological stress causes hyperactivity in the autonomic nervous system, which leads to the activation of Trigger Points.
This in turn leads to increased muscle tension, muscular pain and pain referral.
The acupuncture point large intestine 4, located in the web between thumb and index finger is frequently used in treatment of headaches. The innervation of the Muscle Adductor Pollicis is T1, which coincidently forms part of the autonomic nervous system supply to the head.
When talking to a person with a TTHA, there are usually a combination of factors that lead up to the headache.
Treatment
People who suffer Tension headaches frequently use Painkillers to relieve their pain. It is worth noting that those who frequently use painkillers fail to realise that the headaches they endure may well be caused the painkillers they take on a daily basis. This is more frequent than you would think, it is called a "Rebound Headache".
Most people with TTHA will use an analgesic or NSAID, bought over the counter from their pharmacy.
Many people have never tried an alternative :
Osteopathic Manipulation, Acupuncture or CST, for example. A combination of these treatments will often give excellent results.
Dural Bridge
There is a connection between the deep cervical muscles and the dura mater, the membrane that lines the cranium. A muscle called the rectus capitis posterior minor has a slip of tissue that attaches to the dura mater at the spinal level C1/C2. When this muscle is abnormally contracted it can traction the dura mater and cause a headache.
Migraine and Tension Type Headaches
Many people who suffer from MIGS also suffer from TTHA. This is probably when the myofascial component is large, and the emotional and vascular component are small. Often, people will experience a constant, low grade background ache. This is chronic, and needs intervention.
Cluster Headaches/Migrinious Neuralgia
This is a relatively rare condition, and has to be differentiated from migraine, as the treatment is different. Predominantly affecting men between 40 & 60 years of age. Characterised by excruciating pain around the eye, spreading to the temple and face. There is profuse watering of the eye and stuffiness of the nose. Each attack lasts 20 to 120 minutes, once or several times a day. A "Cluster" may last 6 to 8 weeks. I have never treated this condition, and I believe it does not respond to Acupuncture or CST. Medication such as an Ergotamine suppository is recommended, as is Lithium Carbonate and Nifedapine.
Tempo-Mandibular Pain (TMJ)
TMJ Pain is common, and many people have "Clicky" Jaws. I believe that the majority of people suffering this condition have Trigger Points in their facial muscles. With judicious examination the offending muscles can be found, and application of pressure will elicit the pain.
TMJ Syndrome usually accompanies people who clench and grind their teeth. The tension of continually contracting the muscles of mastication will cause trigger points to develop, and pain referral to specific areas of the face and teeth will then ensue.
Where people have toothache, but there are no problems to be found with the teeth, it is most likely that the pain has its source in the facial muscles.
These TPs can refer pain to the teeth, ear and face. They can be worked on using acupuncture or deep massage. (With the practitioner wearing latex gloves as it is neccesary to work inside the mouth.)
Again, the teeth are a major site of pain referral.
Trigger Points in the Diagrastic Muscle
Pain can come from obscure muscles, that are often overlooked. This muscle is called The Diagastric as it has 2 muscle bellies. It runs from the Mastoid Process to the Hyoid Bone and then to the Symphysis Menti on the Mandible. It is involved in swallowing, as it elevated the Hyoid Bone. Again the teeth are a prime site of pain referral.
Sinusitis
Sinuses are located in the Frontal, Ethmoid, Maxilla and Sphenoid Bones. They are hollow areas within these bones. They produce mucous, lighten the skull weight, and serve to make sound resonate. They warm air and filter it when breathing through the nose. Sinuses can become infected, and when this happens they produce a discharge, a runny nose and are the area is inflamed and painful. When there is sinus pain, but no discharge or indication of infection the pain may well be referred.
A Scientist called Hans Selye developed the General Adaptive Syndrome (GAS) in 1936. Basically, what he discovered was that prolonged stress leads to three things: Gastric Ulceration, Adrenal Hypertrophy and Decreased Immunity.
So in simple terms you get poor digestion and stomach pain, chronic fatigue and catch every bug on the go. Add to this hypertension, disrupted sleep, muscle tension, eczema, asthma etc… Stress is endemic and I am sure it is the major contributor to poor health in the 21st Century. Just see how many people are taking an anti-depressant of one sort or another.
There is a dichotomy here, and this deals with PAIN. When a person is in pain, they are very stressed, and how often is a person who is in chronic pain told by some "Wise" person that their pain is stress related or "It is all in your mind"? This is a cop out! It's akin to the response : "You have a virus" when the GP has not a clue what the problem is.
People are still sent to Psychiatrists when they are in chronic pain as a result of Trigger Points, and given Anti-Depressants. Luckily, a side effect of an anti-depressant like Amitryptaline is analgesia, and helps with neurological pain, and to a lesser degree muscle pain. A lucky quirk, like Viagra, which was originally developed as a drug to deal with Pulmonary Hypertension.
When you help a person who is in pain their stress levels decease immensely. You have a person in agony, who is grey with pain, and next time you see them they are back to their cheery, happy selves. Their stress level has dropped considerably. It is important to differentiate where the stress is coming from. If a person is genuinely unhappy with their lot, their stress will often be the root of their pain. But if a person has bent over in the garden, and their back has "Gone Out" their stress will probably be pain related. This information will normally come out when you meet and talk to the person about their medical history.