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Treating Headaches with Physical Therapy

Did you know that PT can be used to treat headaches? In this episode of MossRehab Conversations: Therapy Edition, Trish Crane, PT, Clinical Manager of MossRehab Plymouth Meeting, and John Morris, PT, Clinical Manager of MossRehab Lansdale, talk about the latest physical therapies for treating cervicogenic headaches.

Welcome to another episode of MossRehab Conversations: Therapy Edition, where clinicians at this nationally ranked physical rehab facility come together to share their expertise. The topic this time, cervicogenic headaches. We join Trish Crane, Clinical Manager at MossRehab Plymouth Meeting and faculty member in the Orthopedic PT Residency program. As she speaks with John Morris, Clinical Manager of MossRehab Lansdale, where he also serves as Director of the Orthopedic Residency program for physical therapists. Morris is board certified in orthopedics through the APTA and is a fellow of the American Academy of Orthopedic Manual Physical Therapy.

Hi, John, thanks so much for speaking with me today. We're really excited to have you here to talk about a topic that impacts everyone I know, a headache. When I think of treating a headache, physical therapy isn't necessarily the first thing that comes to mind. So, I guess my first question is, are there specific types of headaches that can be successfully managed using physical therapy?

Yes, there are. But first thanks and foremost, I really appreciate this opportunity to speak with you on a topic that I'm very passionate about. Treating headaches is very challenging, but also really rewarding for me. Sometimes the biggest challenge is getting patients in the door with these conditions. As you indicated it's not common for folks to know that a physical therapist can help people with headaches. The most common types of headaches are migraines, tensions, cluster headaches, and cervicogenic headaches. And they're all primarily categorized based on their signs and symptoms as well as have unique recommended management strategies. Cervicogenic headaches are the subgroup that benefit the most from physical therapy.

So, what makes a cervicogenic headache different from the other types of headaches?

The common features of a cervicogenic headache is going to be someone having again, a headache, it's usually unilateral, so on one side. It's intermittent in nature, so it's not going to be constant, but the headache is going to come on near the same time as someone reporting neck pain or neck stiffness that can be experiencing muscle spasms and or may also have a loss of motion in one or multiple directions in their cervical spine.

Are there particular injuries or patient populations that you find cervicogenic headaches are more prevalent?       

Again, those people with recurrent neck pain is definitely one. So, if someone has some pain in the neck and maybe some mobility restrictions, I'm often going to ask if they also experienced headaches. It's also important to consider people who have had trauma or whiplash injuries, or maybe those who have to spend a lot of time at their desks, so they're sitting in prolonged poor postural positions as well.

With the pandemic, there are a lot of people working from home and lots of people that don't have great work set ups at home. One of the things I've noticed in our clinics are that there are referrals for many different diagnoses that are related to changes in lifestyles, based on the pandemic. Have you noticed an uptick in cervicogenic headaches being referred to your clinic because of workstations set up from working at home?

I'm definitely seeing an increase in headache referrals, but I would say what I'm seeing even more so is patients coming in with neck pain. In my interview, I'm asking if they're also reporting headaches and I'm definitely seeing an increase incidence of that. This COVID pandemic has really changed a lot of people's lives. People's workstations probably aren't set up at home as well as they are in the office per se. And definitely there's been an uptake in those, "Oh yeah, you know what? I've also been getting headaches at the same time." Is a common answer out here. And so I would say, yes.

Are there any diagnostic tests, like an MRI or an x-ray or a CT scan that exists to help rule in this type of cervicogenic headache?    

Unfortunately, no, at least not at this time. In fact, many patients with these types of headaches are going to have completely normal imaging, but a physical therapist will perform a very thorough clinical exam. And that's really, really helpful in both ruling in and ruling out these types of cervicogenic headaches.

Are there other signs that should alert a person with a headache, they should see a physician as opposed to a physical therapist. 

From a precautionary standpoint, if the headache is very severe and comes on very, very suddenly, they definitely should be having a conversation with their doctor. Additionally, there are some other flags or signs that we need to be sensitive to. Are they getting dizzy at the same time, feeling nauseous, double vision, even difficulty walking or numbness anywhere? I think those also definitely warrant a discussion with your physician. My concern is those symptoms could be associated with something more serious. And as a reminder, Dr. Miriam Segal, is one of our MossRehab physicians who also specializes in headache disorders, she could be a good person to consult with if you are concerned that your headache is something more serious.

How prevalent are cervicogenic headaches?      

Prevalence in the literature ranges anywhere from 0.4 to two and a half percent in the general population. But some of the newer literature is prevailing that almost 15 to 20% of those who suffer from chronic or recurrent headaches that those may be cervicogenic in nature and women are also four times more likely than men to suffer from these types of headaches as well.

Is there such a thing as the headache being of mixed origin? Can they have cervicogenic headaches along with tension headaches?

Yes, there is. One of the challenges between all of these headaches, if you look through the literature, is there is some cross mingling as far as associated signs and symptoms. Certainly someone who has a migraine, they may also have some neck issues that could be causing a cervicogenic headache as well, just as an example.

What does the physical therapy treatment for the cervicogenic headache look like?   

A physical therapist will perform a very thorough exam. They're going to review all the patient's medical history. They're going to discuss their history as well. What the patterns of pain look like? What are the behaviors of pain? And then they're going to do an exam. So they're going to look at the patient's posture. They're going to look at their neck mobility as well as the strength and the control for that region. And then treatment is focused on restoring some of that mobility in the spine using manual therapy to the cervical and thoracic spine, but also exercise addressing any strength and endurance deficits that are identified.

Is there research to support physical therapy management of headaches?        

Yeah, there is. The combination of manual therapy and exercise has proven to reduce the symptoms and the 2017 Neck Pain Clinical Practice Guideline highlights intervention strategies. So, they recommend upper cervical mobilization and exercise for those with acute and subacute headaches. And then also want you to incorporate thoracic mobilization as well beyond the cervical mobilization and exercise for those who are more chronic in nature.

How effective is physical therapy management for these headaches?

The research findings have demonstrated that it can significantly reduce patient's symptoms, especially the frequency, duration, and intensity. And in another study examining the use of medication found that patients in an experimental group receiving physical therapy had a reduced use of medication afterwards. And in summary, the research indicates it can be very effective and it can be effective in a short time too, which is important.

What advice would you give to people who are suffering from headache?

First, I would say it's very common. Current literature says half of the adult population will have a headache at least once a year. And at 83 to 93% of the adult population will experience it at any point in their life. However, even though it's regular, we have to recognize that it can be repetitive or recurrent and it can lead to long-term pain, it can lead to disability or diminished quality of life. And there may be some associated financial costs as well, certainly if you're missing work. I would say if you're suffering from recurrent headaches and you also have concurrent neck pain or neck stiffness, you should consider talking to your physician and inquire about physical therapy.

Is there anything new or innovative with regards to physical therapy management of cervicogenic headaches?    

Although there's nothing new, people are starting to realize that these types of headaches are influenced by the spine and that physical therapy can be a really great benefit for them in managing this condition.

You mentioned a lack of awareness of the role of physical therapy to manage headache as being a barrier to getting people through the door if you will, what can we do to that awareness to the general public as well as who are referral sources?

I really think this lack of knowledge starts with our healthcare providers. I think that's the main barrier. Worldwide, only about four hours of undergrad medical education is dedicated to headache disorders. I always bring up the statistic because it's so surprising to me. And, the poor awareness extends to the public. Headache disorders aren't considered serious by many, since they're episodic, they don't cause death, and they're not contagious. And, the low consultation rates in many countries may also indicate that patients are unaware that there's effective treatment. Some of the more current findings reveal that half of people with headaches are just self managing it with rest and pain medication. But although cervicogenic headaches are not considered to be serious by some, we have to realize it has a long-term impact on the quality of life. And we as physical therapists have to continue to educate the general public, as well as our referring physicians about the common signs associated with cervicogenic headaches. And more importantly, how we can play a critical role in providing relief from these symptoms.

Wow, this is all great information, thank you so much. And to highlight our role as advocates for being able to educate the public and our referral sources and even our own colleagues is really where you see the profession moving to the future. So, thank you so much for your time and for your expertise.

No, thank you for bringing me on. I really appreciate the opportunity.

That was John Morris, Director of the Orthopedic Residency Program for a physical therapist and Clinical Manager of MossRehab Lansdale. To learn more about MossRehab's work in this field, go to MossRehab.com also on the web at MossRehab.com/conversations, you can listen in as we talk with pioneers in physical medicine and rehabilitation from around the globe. I'm Bill Fantini, thanks for joining us on MossRehab Conversations: Therapy Edition.

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