MidAmerican Neuroscience Institute's physical therapist, Amy Nichols, DPT shares a presentation about her role in the Institutes Headache Center. She explains to a montly headache support group the evaluation and treatments that physical therapy provides for chronic daily migraine and other challenging headaches. The Institute has a high success rate with headaches with a integrated approach of neurology, physical therapy and sleep clinic coordinated at one location in the Kansas City area. www.neurokc.com

1. Physical Therapy’s role in
headache treatment
Amy Nichols, DPT
MidAmerica Neuroscience Institute

2. About me
• MidAmerica Neuroscience Institute
– Consultants in Neurology
– MidAmerica Neuroscience Foundation

3. Physical Therapy Presentation to
Headache Support Group

4. Headache Occurrence
• 2 out of 3 children will experience a
headache by the age of 15
• 9 out of 10 adults will experience a
headache in their lifetime
• It is the most common form of pain and
the most common reason for missing
work
• Estimated about 45 million American’s
suffer from chronic headaches
•NIH.gov
About 70% of sufferers are women

5. International Classification of Headache Disorders
• Published by the International Headache
Society
• Classifies more than 150 types of primary
and secondary headache disorders

6. Primary vs. Secondary
• Primary headaches- occur independently, rather
than as a side affect of another medical
condition. (Migraine, tension, cluster, and
miscellaneous)
• Secondary headaches- symptoms of another
medical condition. (head/neck trauma,
cranial/cervical vascular disorder, non-vascular
intracranial disorder, substance or substance
withdrawal, infection, disorder of homoeostasis,
disorder of cranium/neck/eyes/ears/nose/sinus/
teeth/mouth/other facial/cranial structure,
psychiatric disorder )

7. Physical Therapy Evaluation
• Subjective
– Headache diary?
– Frequency, intensity, duration, location?
– Limitations at work and home?
– What are their symptoms?
– Is there more than one type?
– Recent onset or past medical history of headaches?
– Recent change in headaches?
– Does anything relieve or aggravate symptoms?
– Has the patient recently started a new medication?
– Is there neck pain/shoulder pain? And does it occur
with or without the headaches?
– Sleep position?

8. Subjective Evaluation
• Headache journal
– Time of day
– Duration
– Intensity
– Symptoms
– Activity prior to episode
– Medications prior or after episode
– Amount of sleep the previous night
– Emotional condition
– Weather or daily activity
– Foods consumed in the past 24 hours
– Menstrual cycle

9. Objective Evaluation
• Posture Assessment (Gown for females,
generally shirtless for males)
• Posterior View
– Scapular position
– Cervical position
– Weight bearing/trunk lean

10. Video From Live Presentation

11. Objective Evaluation
• Side view
– Plum line alignment
– Presence of humeral
internal rotation
– Trunk position
– CT junction
– OA position

12. Objective Evaluation
• AROM/PROM: scapular upward rotation,
shoulder flexion/ER/IR, cervical rotation,
flexion, extension, forward head posture
• Strength
• Reflexes
• Sensation
• Manual Assessment of spinal movement
• Soft tissue assessment of muscle tightness

13. Myofascial trigger points
• Presence of trigger points: hyperirritable spots
in skeletal muscle that are associated with
palpable nodules in taut bands or muscle
fibers
• Active trigger points- actively refers pain
locally or to a referred area.
• Dormant/Latent trigger points- does not yet
refer pain, but may do so when pressure or
strain is applied.
Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger points, neck mobility and forward
head posture in unilateral migraine. Cephalalgia 2006; 26:1061-1070.

14. Myofascial trigger points
• Caused by acute or chronic muscle
overload, activation, disease, psychological
distress, homeostatic imbalances, direct
microtrauma or macrotrauma.
Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger points, neck mobility and forward
head posture in unilateral migraine. Cephalalgia 2006; 26:1061-1070.

15. Myofascial Trigger Points
Type of Headache Probability of
myofascial trigger point
Migraine High
Tension-type Headache Very high
Cluster Low to moderate
Miscellaneous vascular Low
Associated with nonvascular Low
intracranial disorder
Associated with substances or their Low to high
withdrawal
Associated with noncephalic infection Low
Associated with metabolic disorder Low
Cervicogenic headache High
Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1,
2nd edn. Baltimore: Williams & Wilkins 1999.

16. Trigger Points
Upper Trapezius
Sternocleidomastoid
Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd
edn. Baltimore: Williams & Wilkins 1999.

17. Trigger Points
Suboccipitals Splenius Capitis
Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd
edn. Baltimore: Williams & Wilkins 1999.

18. Initial Evaluation
• Educate Patient on condition
– MRI’s, objective measurements found, reference to
spinal/scapular model, Netter’s Anatomy, Travell and Simmons
– Send relevant information home for the patient (posture
correction, computer sitting posture, etc.)
Headache triggers
Headache threshold
150
100 Cervicogenic
Blood pressure
50
Myofascial Trigger Points
0
ay
ay
ay
y
y
da
da
sd
sd
id
es
on
Fr
ur
ne
Tu
M
Th
ed
W
Days of the week

19. Follow Up visits
• Manual Therapy
• Therapeutic Exercise
– Cervical strengthening
– Scapular strengthening
– Stretching
• Neuromuscular Re Education/ Therapeutic Activities
– Posture correction
– ADL correction
– Taping

20. Proper Desk Posture
• Imagine Plum line
intersecting ear, shoulders
and hips
• Maintain Lumbar,
Thoracic and Cervical
natural cures
• Keep the top of the
monitor at the top of the
head, to maintain about
20-30 degrees of eyesight
below the horizontal
• Keep a comfortable
viewing distance about
22inches away
• Look away from the
monitor at least once every
30 minutes
• Keep documents at a close
viewing level

21. Resources
• American Headache Society- group of
health care providers dedicated to the
study and treatment of head and face
pain. Publish the medical journal
Headache. Sponsor the AHS Committee
for Headache Education (ACHE)
• http://www.americanheadachesociety.org
• http://www.achenet.org/
- (MIDAS) Migraine Disability
Assessment Test, Trigger handouts,
headache log information

22. Resources
• International Headache Society- world resource
information, publish Cephalalgia. Has a member and
non-member portion of the website. Learning center,
IHS guidelines
http://www.i-h-s.org/

23. Resources
• The National Headache Foundation-
goal is to enhance the healthcare of
headache sufferers
http://www.headaches.org/
• “Headache U”- Chart your course to relief
• Educational modules
• Physician finder
• Patient oriented

24. Resources
• The National Institute of Health’s National
Institute of Neurological Disorders and
Stroke
– Mission is to reduce the burden of
neurological diseases
http://www.ninds.nih.gov/index.htm
• Information for clinicians and patients
• A to Z disorder summaries
• Clinical Trial information for researchers and patients

25. References
• Borsa PA, Timmons MK, Sauers EL. Scapular-Positioning Patterns During
Humeral Elevation in Unimpaired Shoulders. J Athl Train. 2003 Jan-Mar, 38(1):
12-17.
• Yinen J., Takala E., Nykanen M, et al. Active Neck Muscle Training in the
Treatment of Chronic Neck Pain in Women: A Randomized Controlled Trial.
JAMA. 2003; 289(19):2509-2516.
• National Institute of Health, National Institute of Neurological Conditions and
Stroke headache information page.
http://www.ninds.nih.gov/disorders/headache/headache.htm
• Schwedt, T., R.E. Shapiro, Funding of research on headache disorders by the
National Institutes of Health. Headache. 49:162-169 (2009).
• Headache Classification Subcommittee of the International Headache Society.
The International Classification of Headache Disorders. Cephalalgia. 2004;
24(suppl 1):1:160. http://ihs-classification.org.en
• Hoving J, et al. Manual therapy, Physical Therapy or Continued Care by a
General Practitioner for Patients with Neck Pain. Ann Intern Med. 2002;
136:713-722.
• Quinn C, Chandler C, Moraska A. Massage Therapy and Frequency of Chronic
Headaches. American Journal of Public Health Oct. 2002, Vol 92, No. 10.

26. References
• Cools AM, et al. Rehabiliation of Scapular Muscle Balance: Which Exercises to
Prescribe? American Journal of Sports Medicine 2007 35: 1744.
• Roth JK, Roth Rs, Weintraub JR, Simons DG. Cervicogenic headache caused by
myofascial trigger points in the sternocleidomastoid: a case report. Cephalalgia,
2007, 27, 375-380
• Biondi D. Cervicogenic headache: mechanisms, evaluation, and treatment
strategies. JAOA. 2000; 100:9.
• Fernandez-de-las-Penas C, Cuadrado ML & Pareja JA. Myofascial trigger
points, neck mobility and forward head posture in unilateral migraine.
Cephalalgia 2006; 26:1061-1070.
• Silberstein SD, Lipton RB, Dalessio DJ. Overview, diagnosis, and classification.
In: Silberstein SD,Lipton RB, Dalessio DJ, eds. Wolff’s Headache And Other Head
Pain. 7th ed. Oxford, England:Oxford University Press; 2001:20.
• Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger
point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins 1999.
• Bendtsen L, Jensen R, Jensen NK, Olesen J. Muscle palpation with controlled
finger pressure: new equipment for the study of tender myofascial tissues. Pain,
1994, 59:235-239.