4.11: Migraines and Tension-Type Headaches

With an estimated three billion individuals world-wide living with migraine or tension-type headache The Global Burden of Diseases, Injuries, and Risk Factors list migraine and tension-type headaches as one of the leading causes of disability worldwide (GBD 2016 Headache Collaborators).

Pathophysiology

Migraine has two major types.

1. Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms.
2. Migraine with aura is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a prodromal phase, occurring hours or days before the headache, and/or a postdromal phase following headache resolution. Prodromal and postdromal symptoms include hyperactivity, hypoactivity, depression, cravings for particular foods, repetitive yawning, fatigue and neck stiffness and/or pain.

Tension-type headache is very common, with a lifetime prevalence in the general population ranging in different studies between 30% and 78%. Tension-type headaches are divided into two categories: episodic and chronic.

TED-ED: What Causes Headaches

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Red Flag Screen

• Thunderclap headache – a severe headache reaching at least 7 (out of 10) in intensity within 1 min of onset
• Fever and meningitis
• New headache with cognitive change in an elderly patient

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question
• Patient Specific Functional Scale
• Headache Impact Test 6-item (HIT-6)
• Migraine-Specific Quality of Life Questionnaire (MSQ v2.1)
• Patient Perception of Migraine Questionnaire (PPMQ-R)
• The Migraine Disability Assessment (MIDAS)
• Headache Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of tension-type headache or migraine and interpret examination results in the context of all clinical exam findings.

• Cervical Flexion-Rotation Test
• Trigger point palpation of the cranio-cervical muscles
• Manual screening of the cervical spine

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. For patients with persisting headaches, it is important to work with the patient and their physician to develop strategies to manage symptoms. For people who suffer from migraine and tension-type headaches soft tissue irritation and nerve sensitization may be a major contributor to symptoms (Do et al., 2018). Gentle manual therapy of the upper cervical spine may help avoid ongoing nociceptive input into the trigeminocervical complex (Luedtke et al., 2017). Structures to keep in mind while assessing and treating patients suffering from headaches may include neurovascular structures and investing fascia of:

• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)
• Levator Scapula
• Longus Colli & Capitis
• Rhomboid Minor and Major
• Occipitofrontalis
• Corrugator Supercilii
• Sternocleidomastoid
• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
• Temporomandibular Joint
  • Medial Pterygoid
  • Temporalis
  • Masseter
  • Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)
  • Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as self-massage, and mindfulness-based stress reduction has been shown to be safe and effective for reducing headaches, with little to no side effects (Seminowicz et al., 2020).

Prognosis

Globally physicians, now more than ever are recommending complementary treatment options (i.e., manual therapy, acupuncture, mindfulness-based stress reduction, pain neuroscience education, and exercise) as part of a multi-modal approach to decrease the individual’s headache frequency, intensity, duration and acute medication requirements. Massage therapy specifically is included in several clinical practice guidelines for the treatment of headaches (Busse et al., 2017; Côté et al., 2019)

Massage Sloth: Myofascial Release for Headache

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for tension-type headaches and migraines based on patient-specific assessment findings including, but not limited to:

• Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
• Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
• Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
• Hydrotherapy (hot & cold)
• Self-Management Strategies (e.g., engaging in physical activity and exercise, mindfulness-based interventions, and healthy sleep habits)

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