Teenage Headaches

[raafox]

Hi all,

first of all thanks for reading my post, I look forward to your words of wisdom in dealing with this problem patient.
I have a 15 year female patient who has a history of insidious onset of constant headaches dating back approximately since last summer. She has been to her doctor and had many tests including an MRI of her head which came back clear, also has tried migraine medications with no relief and has now been referred to physio for help with pain. Also 3-4 years ago she had a 5cm leg length difference that was treated with a shoe raise that she no longer requires.

On assessment she is tall, athletic build(5'9") with reasonable posture, no obvious deformities or deviations, no sign of previous misalignment from leg length evident.
Cervical rangoe of motion is good, patient feels a contralateral stretch at end of range with rotations, nil of note when side flexing, pain into the top of her head on forward flexion and pain around C1-2 with extension, note - patient tends to chin poke when going into extension and not use her lower cervical vertebrae to move.
On palpation there is multiple cavitation from the thoracic spine throughout and her pain is easily stirred up with muscular palpation of upper traps and levator scapulae.

Patient trains upto 3 times a week at handball (goal keeper) and also running training, handball is one of the only times she doesn't feel the pain in her head, it does however return quickly once training has stopped, running tends to aggravate her symptoms. Patient reports being poor with stretches in general.
Other Hobbies - patient tends to watch films on her ipad in bed

Patient also reports occasional difficulties with swallowing, some dizziness and sickness when the headaches are bad, and infrequent episodes of 10 seconds of double/blurred vision at times with school work.

Initally treatment was aimed at local soft tissue work, thoracic mobilisations and a home stretching programme but very little benefit has been gained from local treatment of the muscles, it actually seems to aggravate her in the short term nad have no carry over. Even simple thoracic extensions on a towel on the floor cause pain and have been altered to stretching without the towel and the use of a pillow for her head. I have also trialled cervical mobilisation, more recently I began correcting the movement pattern of her chin poke in extension and scapula retraction exercises. Today as the manual work doesn't seem to be changing things I have opted for acupuncture, the first needle used the patient reported an instant increase in her headache.

As mentioned any ideas or help would be greatly appreciated because at present with such an irritable complaint I am not sure what is the best approach to take going forward.

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[physiobob]

It might be that these are hormonally based headaches that are exacerbated by stress? She is of that age where the effects of hormones can kick in. You could try some light taping to unload or support more the mid thoracic spine rather than the traps which might aggravate her if taped. Focus on the ball and the game is likely to be the reason she has no headaches when playing handball but I would also note that she would be getting a lot of neck 'whip-lashing' type movements being a goalie.

In relation to the biochemistry being involved you could look to the diet and possible supplementation to try to see if it makes any difference to the severity of her symptoms. I would say though that this needs to be preventative as often taking something once a headache is in full swing is not likely to help.

It is also interesting if she does take simple over the counter medications like paracetamol and neurofen plus (with the codeine) to see if either have an effect on the symptoms. This can help add weight to a pathway that the drugs are having an effect on.

Perhaps one last non-musculoskeletal thing to take a look at would be the eyes. If she has a little eye strain, especially with kids and computers then this too could be a contributory factor. Let us know how you get on as teenage headaches can be very difficult to route out the actual cause.

[neurospast]

The information you provide makes me think of poor coordination, general posture. The 5cm leg length discrepancy which disapears indicates a pelvis dysfunction. The whole indicates hypermobility. In general that responds badly on mobilisation, stretching but well on strengthening. Regarding acupuncture initial increase is not necessary a bad response but maybe overdosing (or if you have used GB21 that is the triggerpoint for the uppertraps and an irritation could well result in an increase). Try Li4, Lv3 and stay away from the neck and see what happens. How is the Scapula control and stability?

[Fyzzio]

Hi,
I don't really like to over dramatise symptoms.
But swallowing problems and double vision are central signs. Combined with headaches and dizziness ... that makes me think : neuro

Has she seen a Neurologist or ENT Specialist?

Regards, Fyzzio

[neurospast]

I think Fyzzio makes a good point and in case of no improvement referring on to exclude would be a good idea. Having said that instability (definitely of C0-C2) could cause these symptoms as well. Swallowing: overactive platisma? Blurred vision, dizzyness, headaches? Overload from the neck? Raafox points out that MRI and scans have come out clear but it is not mentioned if the Scans have involved the neck thus possibly the brain is clear but not the neck. How about the jaw?
In principle the the symptoms as problems of swallowing combined with dizzyness and headaches could be caused by stress, hyperventilation, VBI and so on.

[raafox]

Hi all,

thanks for the input so far, keep it coming as it is helping me to cover all areas. So time for a little update on current progress and a few more clues.
Patient reports not having any specialist referral so far only from GP to MRI scan which was of the head and I don't think covered the neck. Neural symptoms at the moment although present seem to be low severity and not worsening, something i will continue to monitor and refer onwards immediately if they worsen or give me cause for concern. Current symptoms today are a little better since receiving acupuncture and patient was keen to continue with it. Patient also reports symptoms are most commonly worse first thing in the morning and also mid to late afternoon at school. Having spent the weekend away she reported feeling better having slept in a softer hotel bed compared to her own bed.
I have advised her to investigate using a different bed at home, variation in her pillows and trying preventative pain meds rather than using them for symptom relief.

I am also considering the idea of hypermobility and will check for markers at the next session and I am also considering strength training long term due to the physical nature of handball here in Norway and my patient's low muscle bulk and flexibility (cervical).
Thanks

[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.