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  • Craig White

Common Causes of Headaches

Updated: May 17

There are over 300 different types of headaches according to the International Headache Society (IHS) 2018. According to this classification system, headaches not associated with a medical condition are known as Primary Headaches, whilst headaches associated with a medical condition are known as Secondary Headaches.


Examples of Primary Headache include Migraine and Tension Type Headaches (TTH), whilst causes of Secondary Headaches include infections, trauma to the head and neck, brain tumors and vascular causes such as an aneurysm or stroke. The most common headache type presenting to osteopaths and GP’s are migraines and tension type headaches (TTH), also known as tension headaches.


Pain from headaches can be throbbing, pressing or squeezing, severity can vary from mild to severe and many people report associated symptoms such as nausea, vomiting, blurred vision, dizziness and sensitivity to light.


Many symptoms of headaches overlap and the classification of headaches by the International Headache Society is only intended for use in research with no practical value in the clinical setting, in other words, it has no use in real life. Many symptoms of migraine, tension headaches and headaches are similar and are increasingly considered by health professionals as being on a continuum, rather than separate entities. Some studies have reported that 75% of patients that suffer migraines, report neck pain associated with their migraine episode.


Common characteristics of migraine are being one sided, pulsatile or throbbing in nature and lasting between 4-72 hours. Tension headaches are classified as affecting both sides of the head (bilateral), lasting 30 minutes to 7 days and cause a pressing pain (non-pulsatile). However, this criteria has been shown to have poor reliability and the percentage of patients who present with headaches on one side versus both sides is similar with migraines and tension headaches. The same study found there was also little difference in the duration of headache, severity, nature (pressing, squeezing and pulsatile/ throbbing) and associated symptoms (nausea or vomiting) between migraine and tension headache sufferers.


There are a number of reasons that headaches may be related to neck dysfunction, common causes include tight muscles, posture related dysfunction as well as a fall or trauma such as a car accident. Tight, irritated muscles known as Trigger Points, often described by patients as a tender lump or knot, have been shown to cause headaches in predictable patterns, depending on the muscle.


Another common link between the neck and headaches is an area of the brain stem call the trigemino-cervical nucleus. The brain stem is responsible for many functions of the head, neck and face such as vision, hearing, balance, muscle control and sensation. The upper part of the neck communicates with this part of the brainstem and so a dysfunction or irritation in one area can affect the other. C2 is a segment at the top of the spine that is often related to headaches and is referred to as a C2 headache. We’ll discuss each of these causes and how they can be treated.


Trigger Point Referral Patterns

Myofascial trigger points were first described by Dr Janet Travell 1942 and have been well established as a cause of muscular pain and restriction. Trigger point maps, help to guide practitioners to the likely source of a patient’s pain, based on the muscle involved.


Travell and Simons have mapped several areas of referral from muscles of the neck including the postural muscles and deep stabilisers of the neck, muscles known as the suboccipitals, the trapezius muscle and the muscles of the jaw. Many of these sites refer pain to the back of the head (the occiput), the temples, forehead and around the eyes. (See Fig. 1)


Figure 1: Trigger Point Referral Patterns (Travell and Simons)


Research by Professor Lorimer Mosley as well as Dr C Chan Gunn around sensitivity of the brain, brain stem and spinal cord may help to explain the severity of pain caused by trigger points and irritated tissues such as spinal joints. Increased sensitivity and overstimulation of the brain and spinal cord is thought to lead to excessive perception of pain. This may enhance the effect of triggers such as food, alcohol, menstrual cycle, fatigue, visual problems, food allergies, jaw dysfunction and gastrointestinal conditions. The body can only cope with so many problems or inputs at a time and if it becomes overwhelmed, such triggers will have far more effect than they might normally have. Stress and anxiety, dehydration, fatigue and lack of sleep will contribute to this state over oversensitivity.


Research by Professor Lorimer Mosley as well as Dr C Chan Gunn around sensitivity of the brain, brain stem and spinal cord may help to explain the severity of pain caused by trigger points and irritated tissues such as spinal joints. Increased sensitivity and overstimulation of the brain and spinal cord is thought to lead to excessive perception of pain. This may enhance the effect of triggers such as food, alcohol, menstrual cycle, fatigue, visual problems, food allergies, jaw dysfunction and gastrointestinal conditions. The body can only cope with so many problems or inputs at a time and if it becomes overwhelmed, such triggers will have far more effect than they might normally have. Stress and anxiety, dehydration, fatigue and lack of sleep will contribute to this stateomrm.ereby affecting the nerves of the brain and spinal cord.he nerves of the brain and spinal cord..rrm.ereby affecting the nerves of the brain and spinal cord.


This concept can help to explain pain in areas that exhibit no signs of injury, trauma or degeneration on x-ray, CT or MRI. This is why patients with signs of degeneration or injury may not be in much pain at all, depending on the level of sensitivity. In other words, just because an x-ray or MRI of a patient’s spine looks bad, it doesn’t mean the patient will be experiencing any pain. In contrast, just because an x-ray or MRI looks good, it doesn’t mean the patient isn’t experiencing pain. Imaging can be an unreliable identifier of pain, if taken in isolation, the patient's symptoms and presentation must be considered in context of any imaging.


The Trigeminocervical Nucleus

Research by Professor Lorimer Mosley as well as Dr C Chan Gunn around sensitivity of the brain, brain stem and spinal cord may help to explain the severity of pain caused by trigger points and irritated tissues such as spinal joints. Increased sensitivity and overstimulation of the brain and spinal cord is thought to lead to excessive perception of pain. This may enhance the effect of triggers such as food, alcohol, menstrual cycle, fatigue, visual problems, food allergies, jaw dysfunction and gastrointestinal conditions.


The body can only cope with so many problems or inputs at a time and if it becomes overwhelmed, such triggers will have far more effect than they might normally have. Stress and anxiety, dehydration, fatigue and lack of sleep will contribute to this state of over oversensitivity, thereby affecting the nerves of the brain and spinal cord.


The anatomical link between the nerves of the face and neck can help explain the relationship between migraine, tension headaches and neck based headaches.


Figure 2:Anatomy of the trigeminocervical nucleus



Treatment of migraines and headaches

Treatment of headaches must first involve a thorough assessment of the patient’s history to identify any contributing factors such as diet, stress, sleep patterns as well as the effects of alcohol and medication. Screening patients for dangerous headaches is also crucial to ensure they are managed appropriately within a hospital emergency department or specialist doctor.


Once all likely causes are identified and potentially dangerous headaches are eliminated, the next step is to identify the tissues that are causing the headache. These are often consistent with the trigger point patterns identified by Travel and Simons (Figure 1) as well as associated with dysfunction in the neck and back. Locating these problematic tissues often involves systematic assessment, which usually involves a momentary aggravation of the headache.


Osteopathic treatment can take a number of approaches, most commonly, decreasing the tightness and spasm in the affected muscles as well as improving joint mobility. This usually involves treating the entire neck and upper back, and often will also involve the shoulder and ribs. Dry needling has been shown to be effective in deactivating the trigger points in muscles and is regularly used as a first line treatment for headache management.


Treatment of headaches by neurologists may involve botulinum (Botox) injections, which targets muscles of the neck, face and jaw. These tissues all receive nerves from the brain stem and or upper neck segments. Botox is a neurotoxin that blocks the nerve signals from the injected muscles and is thought to be the mechanism for relieving pain for migraine sufferers.


Many of the points injected with Botox are the same as points treated with dry needling. Whilst Botox and dry needling have different mechanisms, the concept of dampening down the sensitivity of the nerves in these regions is shared with the two treatment methods. Botox tends to be used when other methods of treatment including medication have failed, whereas dry needling and manual therapy could and probably should be used as a front line treatment once a serious cause of headache has been eliminated.

Figure 3: Common Injection Sites for Botox Treatment for Migraine

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