Chronic headache is the most common neurological complaint presenting to GPs in Australia. (1)
This means it’s likely to be even more widespread than statistics suggest, as many people simply don’t seek medical treatment for chronic pain conditions.
So it’s safe to say, headaches and migraines are kind of a big deal.
Most people experience headache at some point in their life. If it is simply a one off, or infrequent, then most of the time, the best management involves either putting up with it, taking simple over the counter analgaesics or getting treatment from an osteopath (or similar).
However, when headaches are persistent, more targeted management is needed, and the first step is identifying the type of headache you have, which will influence the type of treatment accordingly.
Types of Headache
When it comes to headaches and migraines, there are two broad categories:
- Primary headaches, which the headache is the problem itself. These include migraine, tension type headache, cluster headache and other (less common) primary headaches.
- Secondary headaches, where the headache is a symptom of an underlying condition, including meningitis, brain tumours, aneurysms and brain bleeds. (2)
Because of the serious nature of the underlying conditions that cause secondary headaches, new headaches, particularly very intense or persistent ones, and those with other neurological symptoms like nausea, dizziness, visual changes and loss of balance should be examined by a medical professional.
This post will look at primary headaches and migraines, to give an understanding of the physiology involved as well as treatment options and self-management strategies.
The Headache Continuum
Primary headaches account for 90% of headaches, and are a common cause of visits to health professionals, including osteopaths.
The two most common form of primary headache are migraines and the tension type headache.
Understanding the difference between the two will help identify appropriate management strategies, so an accurate diagnosis is imperative (this means seeking out someone who went to university and studied medicine, not someone who watched an episode of House and wrote in an online forum).
A helpful way to understand the differences between tension type headaches and migraines is by the use of a continuum (3).
Health professionals love a good continuum, and I’m no exception. In the case of headaches, we have migraines on the far left and tension type headaches on the far right.
In terms of the continuum, we have neuro-vascular involvement (migraines) at one end, and psycho-neuro-muscular involvement at the other (tension type headaches).
Though not officially recognised by the International Headache Society (IHS), there tends to be an agreeance amongst many clinicians and academics of the existence of mixed type headaches as well, which would exist about halfway along the continuum.
Finally, for this post, we will consider cervicogenic headaches, as commonly diagnosed by osteopaths and physical therapists, as well as GPs, to be similar to tension type headaches, in that the clinical features and physiology underpinning them is quite similar.
Migraines are typically intense headaches that can last up to 3 days, often accompanied by other neurological symptoms such as photophobia (sensitivity to light) and dizziness. There are two main types of migraine – those with an aura and those without.
Migraines involve the activation of, or the perception of, the activation of the pain-producing innvervation (nerve supply) of the cranial blood vessels. (4)
Diagnosing migraines comes down to a careful history.
As migraines involve a heightened sensitivity to change in stimulus, with a careful history, often triggers can be identified and managed.
Although this is a tedius process, for those sufferers who can identify specific triggers through a process of elimination, managing migraines with lifestyle changes becomes a whole lot more viable.
In addition to lifestyle changes, there are medications which are effective in both the management of acute migraine and in the prevention/reduction of chronic migraine.
For acute migraines, one of the most effective interventions is to take 900 mg of aspirin along with 1000 mg paracetamol. (5)
In some people, NSAIDs (Naproxen, Ibuprofen etc) will have a better effect.
In many cases, there are more specific medications that will work better than those listed, though the list is long-ish, so it might take some trial and error to find out the specific medication and dosage that works for you. Again, work with your doctor, not a blog, to figure out the best approach for you.
Please understand, all medications (in fact, all interventions) have potential side effects, so before you go taking any medications, get medical advice.
Tension Type Headaches
Tension type headaches are mostly diagnosed on an exclusion basis – that is, they don’t have particular features that would classify them as another type of headache. They are the most prevalent form of headache, but often go untreated, as people don’t seek out assistance for them.
The specific patho-physiology of tension-type headaches isn’t clearly understood, but the name implies some form of mental or physical tension involvement, which is agreed upon by headache researchers.
The reason they exist at the opposite end of the continuum to migraines is the absence of vascular involvement. (6)
It is most important to get an accurate diagnosis, as these headaches, are quite a clinical challenge to treat. So if you actually suffer from migraines, but get diagnosed as suffering from tension type headaches, you are potentially missing out on efficacious treatments.
Many people with tension type headaches experience exacerbation in times of psychological or physical stress.
If this is you, pro-actively managing your stress is one of the best preventative treatments available.
Additionally, tension type headaches often have a muscular component – that is, physical tension produced by overactive muscles, usually across the face, head and neck.
Osteopathy For Headaches and Migraines
What is interesting about headaches, is that, in terms of nerve supply, facial and cranial areas are all supplied by the trigeminal nucleus.
So although the cause may differ between a migraine and a tension type headache, the origin, may be the same.
This is clinically significant, because the trigeminal nucleus blends with the nerves from C1, C2 and C3 (the upper part of the neck).
This means that treatment to influence these nerves, can, theoretically, influence all kinds of headache.
Unfortunately, theory doesn’t always translate to practice, but many osteopathic techniques to treat this area relatively safe and risk free, with the big exception being techniques that involve end range rotation of the neck, thus it may be worth exploring.
Additionally, for most people, osteopathic treatment can help relieve some of the systemic effects of headache, including an increased stress response and muscular tension.
Some of these systemic effects include:
- Sympathetic inhibition via rib raising. The sympathetic nervous system is involved in the stress response, including blood vessel dilation/constriction, which can potentially affect migraines. (7)
- Parasympathetic stimulation via manual therapy and breathing exercises (see the image below). The parasympathetic nervous system counteracts the sympathetic nervous system, and stimulation is involved relaxation and recovery from many stress mediated conditions. (8,9)
These manual techniques can be quite effective, however, as previously mentioned, it is important to “treat the person, not the headache” and consider psycho-social variables as well.
An osteopath can help you recognise and deal with particular triggers of migraines or your response to stressors that might be contributing to your tension type headache and if there is further management required, an osteopath will work alongside your “health team” which may include your GP, neurologist and possibly a psychologist to optimise your management.
What Can You Do For A Headache?
Best practice for the treatment of painful conditions involves what is term an “active approach“, that is, an approach where you are engaged in you care and actively participating to achieve a result.
i.e. “doing something”, as opposed to merely showing up and receiving treatment passively, or having something “done to you”.
This means, if you are suffering from headaches you can definitely do a few things that may help relieve or reduce the incidence:
- Educate yourself. Understanding a problem can help you deal with it better. Understanding alone doesn’t seem to improve pain outcomes, but when combined with other active therapies (as listed below) and incorporated into your medical management, it makes a big difference.
- Increase your physical activity. If you don’t meet the guidelines (>30 mins daily of moderate activity), then increasing your activity by walking more will have general health benefits that may improve your headaches.
- Practice mindfulness. Mindfulness helps you deal with stressful situations better. It also “strengthens” your brain, building neural links that are often negatively impacted with pain.
- Sleep better. Improve your sleep hygiene – take electronic devices out of your room, use black out curtains and keep the room slightly cooler than the rest of the house. Additionally, build a bed time routine so that you fall asleep more easily. Fatigue can increase neural sensitivity, and the only way to combat fatigue is with adequate high quality sleep.
- Talk to people. Chronic pain, including headaches, can be quite debilitating, as well as isolating. Talking to others who suffer from headaches/migraines in support groups, or a professional counsellor can help with some of the negative thoughts and feelings that develop around pain and often times make it worse.
The best thing about all of these things, are that they are either free, easy to do or both.
Headaches are debilitating, yet with a proper diagnosis, treatment and management is possible.
This treatment must incorporate biological (physical) as well as psycho-social factors.
Looking at the research on osteopathy/manual therapy and headaches, it can seem that often times “nothing much can be done about them”.
However, when you look at physiological plausible mechanisms of treatment, and apply these to both the causes and origins of headaches, the picture seems more promising.
As always, there is no holy grail, and getting on top of things takes a team effort between yourself and your practitioner(s).
Additionally, there is much you can do for yourself, which, while it may not be “headache specific” can greatly improve your health, wellbeing and potentially your headaches.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.
(1,2, 3) RACGP – Management of Chronic Headache
(4,5,6) Wall and Melzack’s Textbook of Pain
(7) Rib raising and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/20606239
(8) Osteopathic Manipulative Therapy and HRV – unpublished research from London School of Osteopathy
(9) Deep breathing, pain and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/21939499
(10) Relationship between rcpm and dura – http://www.ncbi.nlm.nih.gov/pubmed/8610241