Mystery Cause for Headache

[ehcphysio]

Hi All,

Have a patient who presented with a 4/52 Hx of R) sided Csp pain + headache, worse @ night. No neuro signs, no limitations to AROM and not reproducing with AROM/quadrant. CT scan degen chances at C6-7. BP higher limit of normal. VBI negative. V. stiff and spasm through Csp - treated with mobs, massage and MFR and US, DFN exs and posture advice throughout day and when sleeping.

Now - no pain/headache through day at all, but still getting pain + headache on R) side after several hours of sleep - bad enough to wake and not be able to return to sleep. Been Rx'd Endep - not helping. Completely resolves once upright again after about 30 minute and then no problem throughout the day until sleeping again.

I'm convinced it must be positional - but what am I missing?

Cheers,
Ray

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[asha]

There are too many short forms in your post!!!!!!!!!

[ehcphysio]

Thanks Asha - I'll try and offer some translations...

Csp = Cervical spine
AROM = active range of movement
VBI = Vertebro-basilar artery insufficiency test
MFR = myofascial release
US = ultrasound
DNF = deep neck flexors

Hope that helps...

In an interesting aside the guy dropped in this morning to say that he no longer had neck pain and felt that the headaches were being generated solely on the right posterior aspect of his skull after about 6 hours sleeping in side-lying, then resolved completely once standing....

The plot thickens...

Cheers,
Ray

[asha]

Ray, just find out which side he was sleeping whenever her gets the pain on his right posterior aspect of his skull. This should tell you how else you should mobilise him. Also find out if he supports his head & neck well on the pillow during sleep. best of luck,
asha

[dmariano]

check pillow is a good think...
i think to check if there any trigger point or something...

see ya!

Diego

[ehcphysio]

Thanks for your replies,

He is a side-side sleeper and tends to get the same symptoms no matter what side he sleeps on. We have talked about pillows, sleeping position, stress, etc. His symptoms are reducing and he had 1 pain free night about 5 days ago - however he is also mixing a few medications at the moment (Endep and diazepam) so it's hard to know how much that's contributing... I'll let you know how things develop...

Cheers,
Ray

[junior_physiotherapist]

Hallo Ray,

To try to distinguish the nature of pain so

-pain felt in the morning and diminshes progressivly,as day go by is an indicative of chronic inflamation.
-pain and stiffness felt at the beginning of activity and decrease as the activity continues may indicate a muscle problem.
-pain felt in morning and continues increasing as day go by may indicate a sleeping posture..

Also let ur patient check if s/he have a sinusitis,vision problems,blood problems(as high or low bp),ear problems,....


Hope this could help u!

Regards

[anishkop]

Have you tried mobilising his occipital-atlantal joiints on right side..go deep in there and see what you get after sustained grade 4 mobs. Keep a check for VBI symptoms though

[oscar]

have you tested the endurance of his deep neck stabilisers (e.g with a biofeedback cuff)? I've got a young patient at the moment who gets very bad headaches- absolutley no physical signs other than weakness of her deep neck stabilisers and tension in her occipital muscles (she's had all the usual medical investigations), she's had accupuncture, mobs etc previously with no benefit. I've just started her on a neck stabilisation programme this week for her deep neck musculature...hoping to see an improvement over the coming weeks but it's early days at the moment so I can't comment on whether it will be successful for her....but you could check it out on your chap.

[dhaxelbarqs]

It's caused by the position while sleeping. maybe you should get rid of sleeping on a pillow. It helps.