Nightly headache - tension related?

Hi, just wanted to ask what you do about this (commonly) problem:

Patient; 25y male, always been healthy, paraglider accident 1y ago (with several compression fractures - T12-L1-L2 and a burst fracture L4, posterior interbody fusion L3-L5). He is now almost pain-free (except from coccygus pain).

Pain during day due to the back-related stuff is now almost gone.

BUT: He is facing a tension-related headache in the morning - saying he feels "stiff" in the neck - only the first 30 minutes after he wakes up. He somedays has problems falling a sleep (even at late nights), and he has some nightmares right after falling a sleep. He has changed pillow several times - no difference. He is biting teeth (?) sometimes at night too.

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It seems to me that night-tension is a fairly common thing, do you treat this? How?

It seems like it has a psychogen factor - should he be adviced to somebody with more knowledge?

Any tips or ideas?

Best regards,
Øystein, Norway.

Hi,

It is a common and related problem. If you try to release a tight spot without seeing the whole thing.

Try to learn him how to relax the shoulders and abdominal breathing.

Your guy seems effectively stressed? But why?

What do you mean by "related" (english is not my mother tongue).

I can understand he is stressed, working fulltime as an occupational therapist. Probably a lot could be done here - is it something I could work further on?

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Can not see any other reason to why he is stressed, but I will discuss it with him.

What about that "nightmare"-thing? .. He also told me he sleeps better in the afternoon (after dinner) than at night. He usually doesnt sleep after dinner.

/øystein, PT

I used the term related as linked.
The answers we need are the expectations of this guy.
Nigthmares = what is the recurrent feelings/things.

Try to understand his behaviour.

Hey guys,

His headache may be due to the stiff neck. Ask where his headache is and make him point to it. Might be a good idea to take out the trigger points in the suboccipitals. Also take out the trigger points in the upper traps.

Stress and emotional factors ARE a factor in tension headaches but becoming stress free and emotionally balanced does not reduce the muscle tension once the muscle splints.

His accident may give some info into the neck problem. Did he suffer whiplash? Concussion? Does his head hurt when he exercises? Is his neck always cracking when he does range of motion? Are ther symptoms of TMJ? Pterygoids spastic? Does he wake up with torticollis? How are the scalenes? Does he have rounded shoulders?

Dreams are awsome!!! Including nightmares. Nothing reinforces good "grounded" behaviour by having nightmares of falling out of the sky. :\

Have a good one
Adamo

Well, as I have figured it out the stiff neck causes headache. The origin of the lesser occipital nerve is painfull, I have been working on the sub-occipital musclegroup, with variable effect.

TriggerPoints = ok, working a little on them to relieve pain, but not primary.

Tension could be a multi-aspect case as he earlier suffered a serious concussion from a snowboarding accident, which did heal in 4 weeks (2,5 years ago), now this paraglider accident and then stress at work. The sleep problems became evident about 1/2 year after the paraglider accident.

No exercises pain at all.

No cracking neck when doing range of motion exercises - I have tested flexion, extension, rotation and joint play segmentally from C0 to Th2, a little stiff in the lower cervical, but no "locked" joints.

Temporomandibular joint = no pain, but can not but opens only 5 cm, which I think isn't full. This can be due to the nightly biting. No spastic pterygoidus as I can see.

But what about the dreams?? When facing such patients one wants to "take it by the root", it would have been interesting to find out about this.. I have heard once that if you have stomach-pain you will dream bad dreams, anybody who has heard it? .. Is it possible to find out more about it?

Such stomach pain is close to a "panic disorder"/ distress crisis.

If trapezius are tight, check also latissimus.
Try this => www.somasimple.com/forums....php?t=794

Hi

I am suprised that joint play was negative in the upper C/S. I trust what you are saying but I just want to ask the question to clarify - C1 rot on C2 was equal in feel and motion bilaterally? And O/C1 and C2/3?

With the stomach pain, viscera has fascial connections as well. But fascia is not the only cause of pain (of course). The sympathetic trunk is located just anteriorly to the Costotransverse joints and if he had a nasty accident (which it sounds like he did) then it may well be linked to altered output.

To tell a short but interesting story... This year I had a patient who could not eat a full meal for two years. He literally would only have about 2 mouthfuls before feeling his stomach cramp up and would have to stop eating. He felt no other pain. Examination showed a stiff T/S and L/S. Pelvis was Ok. Less than 4 treatments had him eating a 3 course dinner on his first date with his new girlfriend. He no longer has trouble. Treatments were mobilisation using MET and manipulation of the L/S and T/S. Visceral pain exists because of physical reasons...

Nightmares just after falling asleep is interesting. I suffer from narcolepsy which has as part of the symptoms sleep paralysis. During these attacks (which i haven't had in ages) I would wake up and hallucinate (be dreaming) but couldn't move. They were very vivid dreams. I also learnt that I dropped into REM sleep very quickly (2.5mins) which is when I would start to dream.

The point of the story is that he may be dropping into REM early or rousing himself during REM. As for the content of the dreams, it sounds psychosocial to me if they have recurring themes.

Sorry about the long post!

Dreams are a way of the brain to sift through the imformation of the day. Nightmares are very very very important because they reinforce "good behaviour". It's a continuation of the positive/negative reinforcement. Good behaviour stimulates our brain to give feelings of pleasure. Bad behaviour usually causes pain which tells us not to do it again.

Nightmares occur to reinforce the fact that the behaviour the night before or the day before or the month before or the year before would cause a loss of life. It is a defensive mechanism to preserve ourselves. Let your patient understand that and he might deal with them alot better. They start to fade when either he paraglides/snowboards/walk through the woods alone/<insert phobia here> again to reinforce positive feelings with those activities or avoid those activities all together. In both cases they fade away but will return in times of stress or having a bad day with those activities.

Adamo

Agree with much of the above. In addition to other comments; a vertical and anterior compressed AC joint will perputate upper trapezius and sub-occipital tension. If present, treat with an inferior force applied to the acromion in a slightly lateral direction direction also, say 30 degrees. Maintain for 5 minutes. I do this with a folded wash cloth on the shouder and kneel under a table and lift my shoulder into the table. You may add cervical side bending inopposite direction. To move acromion/scapula posteriorly; with folded wash cloth in front of shoulder contact thaanterior portion of the acromion against an outside corner of a wall and lean into the wall for 5 minutes.
Agree with comments re ribs, very critical to test them especially the 1st, 2nd and 3rd as stated earlier the sympathetic chain is fascially attached to the rib heads and sympathetic innervation of head and neck is at those upper segments. The 1st rib can do so much more than is taught. It certainly can get stuck inferiorlyand this is horrible! Can compress medially and this will lock up C7-T1. I evaluate and treat all potential directions if the mobility is impaired and treat both sides and include the manubrium and sternum and costal cartilage anteriorly using standard principles of manual therapy.
I too share the same concern as an earlier clinician regarding the accessory motion of the upper cervical spine. If cleared for unilateral dysfunction, you are then ready to look into bilateral (no-rotatory, non side-glide) mobility impairment, specifically anterior and posterior glide. The mandible can be glided anteriorly on one side or bilaterally. 01, C1, C2, C3 can be glided AP, PA. Stay away from carotid contact! The C2 movement is "paradoxical" in that in flexion it can extend and the opposite is true. It can behave like a circular washer. Test with C spine in full flexion and have client perform anterior glides, posterior glides and if extension has been cleared do same in extension. This is an effective way to treat the paradoxical accessory motion at C2.
I could go on and on but will wrap this up. The upper 3 cervical segments join up with the trigeminal nucleus and trigeminal plexus within the spinal cord, this is called the cervico-trigeminal nucleus. Thus an upper cervical nerve irritation can enhance muscle tension in the masticatory system and evade diagnosis, be misdiagnosed as TMJD, or of course can be concomitant to the TMJD.
In addition to the usual unilateral TMJ mobilization, I treat bilaterally with mandible in varying degrees of opening, treating anterior traction (clasp lower teeth and anterior mandible) or posterior glide (push on anterior mandible) andperform anterior traction to the angle of the mandible bilaterally. That is also a great place to work on myofascial release.
A quick comment on traction to the 01-C1 joint. Contact is on the temples, because that joint is anterior to all the other joints in the neck. Very very gentle traction for 2-5 minutes. An occipital contact will only compress the 01-C1 joints!
All the above comments I hope are additive to the previous commentaries, many good valid points brought up by previous posts. I think there are other professions who can deal with the nightmares better than our profession. Trauma can also deplete the body of micro nutrients, something I learned empirically. Caution is advised though, everyone has advice here, everone is a nutritional "expert" everyone is your best friend when you are ready to buy supplements, etc.
Better go.
Jerry Hesch, MHS, PT
Splintek.com makes an affordable splint, worthy of consideration. Some of the dental splints are immorally priced. I once paid $2,400.00! It was ineffective.

Hi
I expect that your patient has a Post Traumatic Stress Reaction (PTSD). This used to be called shell shock in earlier war environments, but can occur after any trauma. Sleeping at night may give the patient a feeling of loss of control, which he fears. He has associated nightmares with nightime sleep, rather than daytime.
The headaches are definitely from the spine. Deep massage for Levatore Scapulae, plus stretching, should assist in headache reduction. Occipital headache is associated with C2, and frontal headache with C7. Try deep frictions and facet joint glides for these areas.
Nightmares may also occur with circulation problems, caused by sleeping posture. A contour pillow that supports the neck without pushing the head into flexion or lateral flexion, is best. If your patient sleps sitting up during the day without headache, but has headache laying down, suspect posture.

The previous post re coccyx pain needs to be included, as erector spinae tension and neural tethering may contribute to the overall picture. Cerebrospinal fluid increased tension can be aggravated by postural position.
Hope the above helps.
MrPhysio

Here are some poor x-rays to look at. I have ordered the CT scans, but can't tell when I have them posted here.

Regarding sleep and nightly headache it varies a lot. Just had to ask in this forum as it is a thing I have seen several times.

A lot of good posts, I'm sorry to say that there are some things I cant figure out. Whether it's due to a lack of english knowledge or lack of physioT. knowledge depends...

This is a post that I posted in the other post (coccyx pain).

/øystein

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Regarding neural tension:
- Neural radiating diffuse pain after prolonged sitting and stressful days. Somedays even a little burning pain in the skin (about m. tib. ant. and to fibula) on left leg (not the leg with most paresis).
- Hamstring tension is a little variable - (Straight legs then fingers to floor distance is 10 - 20 cm). Sitting like doing slump test ("potato-bag" - thoracic flexion) and then flexing neck gives discomfort in upper cervical, and at about Th5-6 and also a little pain about L3-4. No radiating pain doing that.
- Paravertebral muscles in thoracic spine (also cervicothoracic junction) are frequently tensioned with a numb feeling in the skin (during stressful days and in running on higher speeds for longer time) mobilisation is then useful.

Regarding Coccyx:
- After a more thorough/detailed palpation of the coccyx I find the following: Seems to be aligned equally from the tuber ischii. But: The ligaments on the right side of the coccyx are by far more firm than on the left side. After palpating some minutes the local pain disappear in the sacrotuberous lig., but applying pressure to the tip of coccyx is still painful. Could the sacrotuberous lig. be sprained? .. what about injections, could this be helpful? prolotherapy? ..

Regarding muscle length of erector spina:
- Can not find any special signs of differences between the sides.
- But; quadratus lumborum is constantly under tension. And trying to let go of the quadratus (sitting on one tuber ischii, then lowering the other) on the left side gives immediate pain deep in the muscle (QL), but seems to be referred from the spine (low L5-S1..). Trying the same on the right side does not elicit pain.

Gotta go..

/øystein