1. Cephalalgia Department of Osteopathic Manipulative Medicine University of North Texas Health Science Center Texas College of Osteopathic Medicine

2. Cephalalgia Stuart Williams, DO Associate Professor Department of Osteopathic Manipulative Medicine

3. Case Presentation A 32-year-old female presents to the office with a 10 year history of headaches. The headaches often begin with a sensation of flickering lights. Later she notes a throbbing sensation, usually right or left-sided. She also describes a pressure-like, tight sensation occurring in the occipital area.

4. Case Presentation When the headaches are severe, bright lights and strange smells may provoke or worsen the intensity. The patient will then prefer a dark room. A severe headache in this patient will last several hours. She also describes a chronic, dull achy headache which has lasted several days.

5. ROS No history of head trauma, seizure disorder, or CNS infections. Family history of similar headaches in mother, and maternal grandmother.

6. Physical Examination WDWN female in NAD Alert, oriented x 3 Funduscopic – sharp discs, no hemorrhages, or exudates PERRLA CN 2-12 intact

7. Musculoskeletal Tenderness, tightness suboccipital muscles Elevated left 1 st rib with surrounding spasm Increased spasm in the cervical paravertebral mm. C 3 – C 5, R R S R AA – RR OA – S R R L T 1 – T 4 Increased sympathetic tone, loss of normal kyphotic curvature, S R R L

8. Diagnosis Mixed Tension / Migraine Headaches

9. Differential Diagnosis Migraine Headache Tension Headache Cluster Headache

10. Secondary Headache (Differential) Glaucoma Cerebral Aneurysm Temporal Arteritis Optic Neuritis Carotid or Vertebral a. dissection TMJ Syndrome Herpes Zoster Meningitis/Encephalitis Sinusitis/Facial Osteomyelitis

11. Secondary Headache (Other Causes) Intracranial Hypertension Benign Intracranial Hypertension Exertional Headache (Lift, Cough, Strain) Normal Pressure Hydrocephalus Myofascial Pain Syndrome Subarachnoid Hemorrhage Subdural Hematoma Viremia

12. Secondary Headache (Other Causes) Stroke Vasculitis Cervical Spine Disorder Dental Disorder Anemia Caffeine Withdrawal Fever Hypercapnea Hypoxia

13. Zomig, 2.5 mg at onset of headache Repeat x1 in 2 hours if headache is not resolved Naprosyn 500 mg p.o. Bid. p.c. Treatment

14. Very common in primary care What can be done osteopathically? Mixed Headache with associated Cervical Pain

15. MusculoskeletalSNS & PNS Respiratory and Lymphatic

16. Headache Most common headache is tension. Many patients with migraine headache have coexisting tension headache.

17. Trigeminal Nucleus Caudalis Major Relay Nucleus for head and neck pain. Vascular Headache (Migraine) Nociceptors Vascular Nonnoxious Stimuli Vascular Pulsations Tension Headache Nociceptors Myofascial Nonnoxious Stimuli Muscle Contractions

18. Trigeminal Nucleus Caudalis

20. Trigeminal Nerve: Schema

21. Autonomic Nervous System Involvement Parasympathetic Vagus Nerve (CN X)

22. Vagus Nerve: Schema

23. Cranial Nerve Nuclei in Brainstem: Schema

24. Cranial Nerves: Schema

25. Autonomic Nervous System Involvement Sympathetic T 1 – T 4 ascend to cervical region

26. Autonomic Nervous System Involvement

28. Sympathetic Nervous System

29. Areas to Treat Osteopathically Sympathetic Lower Cervical Upper T-Spine Associated ribs and myofascial attachments Parasympathetic Suboccipital Region

30. Treatments Soft Tissue Soft Tissue Cervical Spine Push-Pull Thoracic Spine Trapezius, Rhomboids

31. Treatments – Soft Tissue (Cervical) Push – Pull

32. Rhomboid Stretch

33. Treatments - Soft Tissue (Thoracic Paravertebral)

34. Treatments – Soft Tissue SNS

35. Treatments – Soft Tissue Trapezius and Rhomboid Stretch

36. Rhomboid Stretch

37. Treatments Muscle Energy Muscle Energy Trapezius and related muscles Cervical Muscles

38. Treatments Muscle Energy (Trapezius)

39. Treatments – Soft Tissue Cervical

40. Treatments Suboccipital Inhibition Suboccipital Inhibition Pads of fingers just beneath superior nuchal line in suboccipital soft tissue. Weight of head rests on pads of fingers.

41. Treatments Suboccipital Inhibition

43. Suboccipital Decompression

44. Treatments 1 st Rib Muscle Energy 1 st Rib Muscle Energy Pads of thumbs on rib heads directly in front of trapezius. Patient should shrug both shoulders towards ears while taking a deep breath. Patient should release breath slowly while letting shoulders down. Continue maintaining firm caudad pressure and follow the rib caudally through exhalation maintaining new position. (Barrier)

45. Treatments 1 st Rib Muscle Energy

46. Treatments Cervical Muscle Energy Diagnosis of Somatic Dysfunction C-Spine Side-bending Rotate each segment

47. Treatments Cervical Muscle Energy Cervical Muscle Energy (C 2 – C 7 ) Induce side-bending to restrictive barrier with pad of thumb. Flex or extend neck to localize to particular segment. Have patient side-bend away from barrier. Side-bend patient to new restrictive barrier.

48. Treatments Cervical Muscle Energy