Massage & Bodywork

November/December 2013

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is to prepare care providers to recommend treatment options with the best outcomes and to provide a common frame of reference for headache researchers. (See the sidebar International Headache Society Classification ICHD-II for a brief overview of ICHD-II classifications.) The headache types that have been found to be most responsive to manual therapies such as chiropractic, massage therapy, and osteopathy include migraines, tension-type headaches (TTHs), and cervicogenic headaches (CGHs). For that reason, the rest of this article will focus on those categories. Migraine Headaches Migraines (from the Greek hemicrania, which denotes the unilateral quality of this type of headache pain) are a common and occasionally incapacitating condition. The World Health Organization now lists migraines among the 20 most debilitating diseases worldwide.1 Migraines have several subtypes, but the two most common versions are migraine without aura and migraine with aura. Most migraines (about 80 percent) do not involve an aura, but when they do, the aura may include auditory, olfactory, or visual stimuli. Auras often precede the headache pain, but may sometimes be present all the way through the process. Migraines used to be considered primarily vascular headaches, involving a demonstrable expanding vasoconstriction followed by extreme vasodilation and inflammation, which exacerbates pain. However, they are now understood to be neurogenic—that is, they are reliant on signals from the trigeminal nerve. The trigeminovascular pathway is recruited as well, but this is a secondary aspect of migraine etiology. People who live with migraines, sometimes called migraineurs, appear to have trigeminal pathways that are more sensitive than those without migraines, even when they have no symptoms. Hyperactivity of the trigeminal pathways puts migraineurs at risk for headache chronicity: episodes can increase in frequency and severity as central sensitization develops. (For more on central sensitization and chronic pain syndromes, see "Pervasive Pain," Massage & Bodywork, March/April 2013, page 42.) Migraineurs also have a higher than usual risk of vascular problems, especially heart attack and stroke. In fact, one type of stroke, called cryptogenic stroke, occurs in younger-than-expected populations and is associated with migraines; it is often linked to a birth defect of the heart called patent foramen ovale ("Patent Foramen Ovale," Massage & Bodywork, October/November 2007, page 126). Migraine triggers include hormonal shifts (especially with the menstrual cycle), lack of sleep, irritating odors and tobacco smoke, fluorescent lighting, weather changes, and several ingested substances, including aged cheeses, red wine, artificial sweeteners, monosodium glutamate, and meat with nitrates. Migraine symptoms usually involve throbbing or pulsing pain on one side of the head, along with nausea, vomiting, and sensitivity to light and sound. Headaches may last 4–72 hours. Some people develop weakness of the facial muscles on the affected side. Pain is made worse by any physical activity or movement, so people in the midst of an episode tend to simply try to sleep. Migraine treatment can be challenging. Interventions are typically used to prevent headaches (prophylaxis), or to stop them midstream, and include analgesics (including opioids), serotonin agonists, antidepressants, and antiepileptic drugs. Tension-Type Headaches TTHs are the most common variety of headache, accounting for about 80 percent of all headache diagnoses. The International Headache Society identifies two main varieties of TTHs: episodic (headaches occur fewer than 15 times per month) and chronic (headaches occur more than 15 times per month). Both peripheral and central nervous system factors appear to be at play with TTHs. Scientists find that peripheral neuron sensitivity is abnormally high, which means that pain perception is abnormally active, but do not find that muscles of the face, head, or neck are unusually tight or guarded. It has also been observed that prolonged input from nociceptors embedded in muscles and fascia around the head can lead to increased headache frequency. In other words, a central-sensitization pain loop becomes established, and, like migraines, episodic TTHs can become a chronic situation. All TTHs have some symptoms in common: they tend to last from 30 minutes to 7 days, they do not involve nausea or vomiting, light and sound sensitivity is minor, they are not exacerbated by low-grade physical activity, the pain they cause is bilaterally mild to moderate, and the pain is often described as "pressing" or "tightening" (as opposed to "pulsing," as in a migraine). See what benefits await you. 45

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