Teenage Headaches

[physiobob]

Patient also reports symptoms are most commonly worse first thing in the morning and also mid to late afternoon at school

Could well indicate dietary/biochemical considerations

[bluebear]

While hormones and stress may play a role, they are only acting on the common underlying problem in ALL headaches types - an overactive brainstem. You need to understand whether or not the neck is playing a significant role in causing the overactivity in the brainstem or not. If it isn't you are wasting her time and money. If it is you need to use headache specific techniques to treat it and she should find some relief within a couple of weeks.

I would try and find a practitioner trained in the Watson Headache approach and get her assessed. If you can't locate one contact Dean or Jane at Watson Headache Clinics (google it) and they might have someone that has been trained on their database in your area (they have trained people in U.K. and elsewhere in the world).

Poke chin, supine or side lie sleeping, watching the ipad in bed and poor posture at school sitting all place the upper cervical spine at C2/3 and below in flexion. This "wedges" the C2/3 disc and causes a milder version of the same internal deformation issues without the frank outer annulus bulges. Check her spinous process of C2. How easy is it to glide with transverse pressure from each side? Does it feel rotated?

A Watson trained practitioner will examine the upper cervical spine for a direct referral to her usual headpain. That's the best place to start in my humble opinion.

Good luck.

Roger O'Toole
Director and Senior Clinician - Melbourne Headache Centre
Melbourne Headache Centre - Headache Treatment, Migraine Treatment,

[physiobob]

ALL headaches types - an overactive brainstem. You need to understand whether or not the neck is playing a significant role in causing the overactivity in the brainstem or not. If it isn't you are wasting her time and money.

Thanks Blue Bear for your comments. As you mention it is not always so black and white and often the neck is merely a symptom of something more central in origin. That said the examination and treatment of that region often results in reduction of symptoms, if not only for them to return if the underlying cause is not addressed. An assessment by someone with an interest in the neck and its relationship to a headache is a worthwhile investment of time and money. After all it might be able to assist rule it out more thoroughly if it is not the primary problem.

I would not suggest she would be wasting her time if the neck was not the problem. The therapist should be ruling it in or out and if it is ruled out then they would move on to examination of other hypotheses and/or refer on to others for advice.

[bluebear]

I would not suggest she would be wasting her time if the neck was not the problem. The therapist should be ruling it in or out and if it is ruled out then they would move on to examination of other hypotheses and/or refer on to others for advice.

My point exactly.
My comment goes to the assessment. How are we "ruling in" or "ruling out" the neck other than by trying treatment and seeing if it works?
If you had an aching pain in the ankle with no history of trauma, you might consider through the course of DDx that you may need to exclude the lumbar spine or neural tissues proximal to the pain. Starting to treat the ankle in that scenario may work, but you may also be treating the wrong body part, and would effectively be a "waste of time" in that a more thorough differential diagnosis might reveal the better place to direct treatment.

I would also argue that, having used "traditional techniques" for many years with varying degrees of success, that there is a significant difference in using headache specific techniques in both assessment and treatment, and the lack of success of traditional approaches would not satisfactorily "rule out" the neck in my opinion.

If cervical retraction is not contraindicated in this person I would try her with passive sustained end of range plus overpressure cervical retraction - 20 second hold x 4. See what effect that has on her headaches if any.

Cheers,
Roger O'Toole
Director and Senior Clinician - Melbourne Headache Centre
Melbourne Headache Centre - Headache Treatment, Migraine Treatment,

[raafox]

If cervical retraction is not contraindicated in this person I would try her with passive sustained end of range plus overpressure cervical retraction - 20 second hold x 4. See what effect that has on her headaches if any.
Melbourne Headache Centre - Headache Treatment, Migraine Treatment,

Thanks for the input Roger, in fact the cervical retraction is one of the first techniques that the patient has reported an easing of symptoms. Nothing dramatic but a definte lessening of pressure and pain in the head. If she tries cervical retraction herself she is unable to achieve the same effect due to the obvious work load and increased tension in her neck muscles. How would you proceed in this situation in terms of treatment approach and also home exercise if any?

Thanks

[bluebear]

If she is showing response to cervical retraction then the neck is definitely involved.

Within treatment you could do Cx retraction, (passive with therapist control and overpressure), hold 20-30 seconds, repeat x 4.

Try active retraction, get her to bring her hands up to her chin to support the head, then relax the neck (i.e. get her to stop pulling her head back and hold it there with her hands). Hold for 20 seconds. Repeat 4 times.

As she gets better at relaxing the Cx muscles, add overpressure with the hands ensuring not pulling the chin down into flexion. Hold for 20 seconds. Repeat x 4. 4 x per day and add during times off increased stress - i.e. after 15-20 mins of watching iPad - you can download apps with reminders on them that will go off to remind her to stretch.

Cervical retraction is far more effective once the underlying issue, being the C2/3 disc has been dealt with. Again, I would seek out someone trained in the Watson Headache approach nearby to assist further should Cx retraction help, but not resolve the issue.

Let me know how you get on.