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Postural and Symptomatic Improvement After Physiotherapy in Patients With Dizziness of Suspected Cervical Origin.

Patients with dizziness of suspected cervical origin are characterized by impaired postural performance. Physiotherapy reduces neck pain and dizziness and improves postural performance. Neck disorders should be considered when assessing patients complaining of dizziness, but alternative diagnoses are common.

Vertigo and dizziness are common complaints accompanying neck pain. The combination of neck disorders with vertigo or dizziness was termed “cervical vertigo” by Ryan and Cope, a designation that may be misleading as most patients suspected of suffering from it report dizziness or dysequilibrium. Owing to its poor definition and the lack of reliable clinical tests, the entity has been the subject of much debate.

There is evidence of a substantial contribution of cervical proprioceptive input to ocular motor control and postural control in both animals and humans, and vestibular and neck proprioceptive information interact linearly in subjective body orientation and mental representation of space. Consequently, disturbed cervical proprioceptive input has been suggested as a probable cause of cervical vertigo, s Information on the orientation of the head in relation to the trunk is necessary for the execution of appropriate postural responses based on vestibulospinal neural output.

The vestibular receptors cannot provide this information, but it has been suggested that it is provided by the cervical proprioceptors. Furthermore, infiltration of local anesthetics into the deep tissues of the neck causes ataxia and nystagmus in animals, but ataxia without nystagmus in humans. Thus, it is reasonable to assume that disturbed cervical proprioception primarily affects postural control in humans, and patients with neck pain and concomitant dizziness have been reported to manifest impaired postural performance, as compared to healthy subjects.

Postural performance can be assessed objectively by posturography, recording the forces actuated by the subject’s feet on the supporting surface. To enhance the sensitivity of posturography in assessing balance disorders, recordings should preferably be made during or after a postural perturbation, This can be accomplished in various ways: by moving the support surface; by the application of erroneous sensory input, eg, by exposing the proprioceptive receptors to a vibratory stimulus; by exposing the vestibular nerves to a galvanic stimulus; or by exposing the subject to visual disturbance in the form of moving surroundings.

Physiotherapy, traction of the neck, injection of local anesthetics at tender points, or immobilization of the neck with a collar have been suggested as treatments for vertigo or dizziness of cervical origin. Among others, deJong and Bles described recovery of postural stability after treatment directed at the neck in occasional patients with dizziness of suspected cervical origin, but to our knowledge there have been no prospective, controlled studies.

In this study, consecutive patients were examined who had recent onset of neck pain and simultaneous complaints of dizziness or vertigo. Extracervical causes of their complaints were excluded when possible, and no medico-legal issues were known to be involved. The aim was to ascertain whether, as compared with healthy subjects, the selected patients have disturbed postural control as objectively analyzed by posturography, and to investigate in a randomized, controlled setting the effects of physiotherapy on postural performance and subjective symptoms of neck pain and dizziness/vertigo.

The performance of patients with dizziness of suspected cervical origin was significantly poorer than that of the healthy controls in the objective tests of postural performance. This indicates that postural control is impaired in these patients and suggests that cervical disorders may affect human balance function. Physiotherapy, aimed to decrease cervical discomfort, objectively improved the disturbed postural performance and reduced subjective symptoms of dizziness and neck pain. Despite the restricted number of patients, the differences between the Treatment group and the Delayed Treatment group, as well as findings within the Delayed Treatment group, suggest that the improvement was a result of the physiotherapy and not merely an effect of general care or reassuring information as to the cause of the symptoms.

Of the 65 patients considered for inclusion in the study, a majority were excluded because extracervical causes were suspected, eg, owing to histories of head or neck trauma with the possibility of traumatic otolith damage or damage to the brainstem, or neck problems secondary to a vestibular lesion. Thus, the mere combination of neck pain and dizziness should not be called cervical dizziness. These findings are in accord with Brandt’s suggestion that well-established signs and tests can yield a convincing alternative diagnosis in many of these patients? It also stresses the necessity of careful history taking and clinical examination, as well as of electronystagmography, before suspecting cervical dizziness. The patients’ subjective complaints of dizziness were classified according to type, and 10 of the patients reported dysequilibrium alone or in combination with vertigo. This is in accord with Brandt’s suggestion that cervical vertigo manifests itself as a feeling of unsteadiness.

The neck muscles were tender on palpation in all included patients, and 13 of the 17 patients also complained of headaches that were of the tension headache type. These cases may belong to a subcategory of the tension headache or tension neck syndrome, and dizziness is reported to be common in these conditions. None of the patients had had extended periods of sick leave, none was retired or opted for early retirement because of neck problems or vertigo, and none stood to gain medicolegal benefit from the outcome of the testing. Thus, malingering is an unlikely cause of the differences between patients and controls in this study, though it cannot be excluded as a possible source of error. If a patient tries to perform poorly in the postnrographic tests, this usually gives rise to a pattern of high-frequency body sway unaffected by the vibratory stimulus. None of the patients manifested such a pattern.

Vibratory stimulus of muscles produces changes in the signalling of the muscle spindles, interpreted by the CNS as indicating a lengthening of the vibrated muscle. This may induce limb, as well as shifts in body posture (vibration-induced body sway). Vibratory stimulus can thus be used as a tool to perturb human stance in a reproducible manner, and has been used in posturographic testing to reveal the effects on postural performance of different factors such as age, drugs, and vestibular or CNS disorders. Repeated posturographic testing may introduce a source of error due to learning effects. However, both Ishizaki and associates and Uimonen and colleagues reported that vibratory-induced body sway in healthy subjects yielded excellent reproducibility without significant learning effects in repeated posturographic testing, both in shortand long-term use.

Posturography has also been used to objectivize positive effects of habituation and balance retraining physical therapy on postural performance in patients with different vestibular disorders but has hitherto only been used in isolated cases to determine the effects of different treatments on dizziness/vertigo of suspected cervical origin. The physical therapy in the present study was aimed at reducing cervical discomfort and did not include vestibular rehabilitation exercises. Thus, the positive findings cannot be attributed solely to habituation of vestibular or postural reflexes. Because there is no gold standard treatment of cervical dizziness, the choice of physiotherapeutic methods was pragmatic and individualized according to signs and findings, and was aimed at reducing cervical discomfort and pain. Thus, the results do not permit meaningful discussion of the choice of physiotherapeutic regimens.

Carlsson and Rosenhal described oculomotor disturbances in patients with tension headache, as compared with healthy subjects, and reported that treatment with physiotherapy or acupuncture, reducing headaches and neck pain, also improved the disturbed oculomotor function. They also found a significant correlation between the degree of tenderness in the trapezius muscle and the severity of oculomotor disturbances. These authors suggested that the improvement in oculomotor function was a consequence of the reduction of neck muscle tension, secondary to reduction of neck muscle pain. Revel and coworkers reported that patients with chronic cervical pain of unspecified origin, as compared to healthy subjects, had poorer ability to reassume the original position of the head after a voluntary active maximal rotation of the head. This was taken as an indication of altered cervicocephalic kinesthesia and neck proprioception in these patients. In a later study, Revel and colleagues also found that a rehabilitation program, based on eye-neck coordination exercises and aimed to improve neck proprioception, significantly improved cervicocephalic kinesthesia and horizontal rotational active range of neck motion, and significantly reduced neck pain in patients with chronic cervical pain syndromes. Similar findings have been reported by Persson and coworkers in patients with cervical root compression due to disc hernias or spondylosis but without medullary compression. After surgical treatment of the root compression, patients manifested significantly improved postural performance and significantly reduced cervical pain. These reports, together with the findings of the present study, suggest that neck disorders per se can in fact cause dizziness.

Women comprised 80% of the referrals and 88% of the final study population. This female preponderance is consistent with that commonly found in different disorders of the neck, such as tension neck syndrome, cervicogenic headache, and tension headache. A similar preponderance of women was found among subjects with vertiginous complaints in a normal population, where approximately 25% to 30% of women complained of vertigo, as compared with only about 5% of men of comparable age. Similarly, the incidence of motion sickness is higher in women. As motion sickness is considered to be caused by mismatch between conflicting vestibular, visual, and proprioceptive stimuli, the skewed sex distribution might reflect greater susceptibility in women also to sensory mismatch involving cervical proprioception.

In the present study the improvement in postural performance was obvious in the posturographic tests in which vibratory stimulus was applied to the calf muscles, but not in the tests in which it was applied to the neck muscles. The patients were improved with regard to neck pain after physiotherapy, but none was completely free from pain. Thus, the muscle spindles of the neck muscles may still be sensitized. As vihration-induced body sway is believed to be induced via stimulation of the muscle spindles, the patients may still have enhanced sensitivity to vibratory stimulation of the neck. Furthermore, Abrahams and Falchetto have reported that electrical stimulation of nerves from the biventer cervicis muscle in cats facilitated the monosynaptic reflexes in the hindlimbs over supratentorial pathways. Hypothetically, the physiotherapy might have resulted in a reduction of sensitivity of the cervical proprioceptors great enough to normalize the gain of the postural reflexes of the lower extremities, thus normalizing the responses to calf muscle vibration, but not sufficiently reduced to normalize the responses to neck muscle vibration.

In the present study, comparison of the patients after physiotherapy to the group of healthy subjects showed the patients’ posmral performance still to be poorer but not in all tests, and the differences between the groups had diminished. Thus physiotherapy improved but did not normalize the patients’ postural performance. Before physiotherapy the patients manifested significantly greater velocity of body sway than did healthy subjects in three of the four stimulus-free periods of quiet stance. After physiotherapy there were no significant differences between the patients and the healthy subjects in any of the stimulus-free periods. Similarily there were no significant differences in any of the four stimulus-free periods between pretreatment and posttreatment values for the patients. These findings emphasize the importance of using perturbation stimuli in posturography to reduce stochastic variations of unperturbed stance if differences between normal subjects and patients with various lesions are to be found.

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Frequently Asked Questions About Headaches

1. What Types of Headaches Are There?

There are several types of headaches - 150 diagnostic headache categories have been established!

Below is a list of the most common types of headaches.

Tension headaches: Also called chronic daily headaches or chronic non-progressive headaches, tension headaches are the most common type of headaches among adults and adolescents. These muscle contraction headaches cause mild to moderate pain and come and go over a prolonged period of time.

Migraines: The exact causes of migraines are unknown, although they are related to blood vessel contractions and other changes in the brain as well as inherited abnormalities in certain areas of the brain. Migraine pain is moderate to severe, often described as pounding, throbbing pain. They can last from 4 hours to 3 days and usually occur 1 to 4 times per month. Migraines are associated with symptoms such as light sensitivity; noise or odors; nausea or vomiting; loss of appetite; and stomach upset or abdominal pain. When a child is having a migraine they often look pale, feel dizzy, have blurred vision, fever, stomach upset, in addition to having the above listed symptoms.

A small percentage of pediatric migraines include recurrent (cyclic) gastrointestinal symptoms, in which vomiting is most common. Cyclic vomiting means that the symptoms occur on a regular basis — about once a month. These types of migraines are sometimes called abdominal migraines.

Mixed headache syndrome: Also called transformed migraines, this is a combination of migraine and tension headaches. Both adults and children experience this type of headache.

Cluster headaches: The least common, although the most severe, type of primary headache, the pain of a cluster headache is intense and may be described as having a burning or piercing quality that is throbbing or constant. The pain is so severe that most cluster headache sufferers cannot sit still and will often pace during an attack. The pain is located behind one eye or in the eye region, without changing sides. The term “cluster headache” refers to headaches that have a characteristic grouping of attacks. Cluster headaches occur one to three times per day during a cluster period, which may last 2 weeks to 3 months. The headaches may disappear completely (go into “remission”) for months or years, only to recur.

Sinus headaches: Sinus headaches are associated with a deep and constant pain in the cheekbones, forehead or bridge of the nose. The pain usually intensifies with sudden head movement or straining and usually occurs with other sinus symptoms, such as nasal discharge, feeling of fullness in the ears, fever, and facial swelling.

Acute headaches: Seen in children, these are headaches that occur suddenly and for the first time and have symptoms that subside after a relatively short period of time. Acute headaches most commonly result in a visit to the pediatrician’s office and/or the emergency room. If there are no neurological signs or symptoms, the most common cause for acute headaches in children and adolescents is a respiratory or sinus infection.

Hormone headaches: Headaches in women are often associated with changing hormone levels that occur during menstruation, pregnancy, and menopause. Chemically induced hormone changes, such as with birth control pills, also trigger headaches in some women.

Chronic progressive headaches: Also called traction or inflammatory headaches, chronic progressive headaches get worse and happen more often over time. These are the least common type of headache, accounting for less than 5% of all headaches in adults and less than 2% of all headaches in kids. Chronic progressive headaches may be the result of an illness or disorder of the brain or skull.

2. Are Headaches Hereditary?

Yes, headaches, especially migraines, have a tendency to run in families. Most children and adolescents (90%) who have migraines have other family members with migraines. When both parents have a history of migraines, there is a 70% chance that the child will also develop migraines. If only one parent has a history of migraines, the risk drops to 25%-50%.

3. What Causes Headaches?

Headache pain results from signals interacting between the brain, blood vessels, and surrounding nerves. During a headache, specific nerves of the blood vessels and head muscles are activated and send pain signals to the brain. It’s not clear, however, why these signals are activated in the first place.

There is a migraine “pain center” or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin, and other inflammatory substances that cause the pulsation to be painful. Serotonin is a naturally occurring chemical essential for certain body processes.

Headaches that occur suddenly (acute-onset) are usually due to an illness, infection, cold or fever. Other conditions that can cause an acute headache include sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat) or otitis (ear infection or inflammation).

In some cases, the headaches may be the result of a blow to the head (trauma) or rarely a sign of a more serious medical condition.

Common causes of tension headaches or chronic nonprogressive headaches include emotional stress related to family and friends, work or school; alcohol use; skipping meals; changes in sleep patterns; excessive medication use; tension and depression. Other causes of tension headaches include eyestrain and neck or back strain due to poor posture.

Headaches can also be triggered by specific environmental factors that are shared in a family’s household, such as exposure to second-hand tobacco smoke strong odors from household chemicals or perfumes, exposure to certain allergens or eating certain foods. Stress, pollution, noise, lighting and weather changes are other environmental factors that can trigger headaches for some people.

Too much physical activity can also trigger a migraine in both adults and children.

Be sure to consult a doctor to find out what is causing your headaches.

4. How Are Headaches Evaluated and Diagnosed?

The good news for headache sufferers is that once a correct headache diagnosis is made, an effective treatment plan can be started.

If you have headache symptoms, the first step is to go to your family doctor. He or she will perform a complete physical examination and a headache evaluation. During the headache evaluation, your headache history and description of the headaches will be evaluated. You will be asked to describe your headache symptoms and characteristics as completely as possible.

A headache evaluation may include a CT scan or MRI if a structural disorder of the central nervous system is suspected. Both of these tests produce cross-sectional images of the brain that can reveal abnormal areas or problems. Skull X-rays are not helpful. An EEG (electroencephalogram) is also unnecessary unless you have experienced a loss of consciousness with a headache. Sinus X-Ray - although the CT scan and MRI provide more details, your doctor may use this test if your symptoms seem to indicate sinus problems. Eye Exam - an eye pressure test performed by an eye doctor (ophthalmologist) will rule out glaucoma or pressure on the optic nerve as causes of headaches. Spinal Tap - a spinal tap is the removal of spinal fluid from the spinal canal (located in the back). This procedure is performed to look for conditions such as infections of the brain or spinal cord. The test can itself cause a temporary headache. Blood Chemistry and Urinalysis. These tests may determine many medical conditions, including diabetes, thyroid problems, and infections, which can cause headaches.

If your headache symptoms become worse or become more frequent despite treatment, ask your doctor for a referral to a specialist. Your family doctor should be able to provide the names of headache specialists. If you need more information, contact one of the organizations in the resource list for a list of member doctors in your state.

5. How Are Headaches Treated?

Your doctor may recommend different types of treatment to try or he or she may recommend further testing, or refer you to a headache specialist. You should establish a reasonable time frame with your family doctor to evaluate your headache symptoms.

The proper treatment will depend on several factors, including the type and frequency of the headache and its cause. Not all headaches require medical attention. Treatment may include education, counseling, stress management, biofeedback and medications. The treatment prescribed for you will be tailored to meet your specific needs.

6. What Medications Can Treat Headaches?

* Aspirin
* Sinus relief medications
* Acetaminophen (Tylenol)
* Non-steroidal anti-inflammatory medications (Aleve)
* Sedatives for sleep
* Codeine and prescription narcotics
* Over-the-counter combination headache remedies containing caffeine (such as Anacin, Excedrin, Bayer Select)
* Ergotamine preparations (such as Cafergot, Migergot, Ergomar, Bellergal-S, Bel-Phen-Ergot S, Phenerbel-S, Ercaf, Wigraine and Cafatine PB)
* Butalbital combination pain-relievers (Goody’s Headache Powder, Supac, Excedrin)

7. What Are Rebound Headaches?

While small amounts of these medications per week may be safe (and effective) — at some point, the continued medication use can lead to the development of low grade headaches that just will not go away.

8. What Food Triggers Headaches?

Some of the most common food, beverages, and additives associated with headaches include:

* Aged cheese, red wine, alcoholic beverages, and some processed meats.
* Food preservatives (or additives) contained in certain foods can trigger headaches. The additives, nitrates and nitrites, dilate blood vessels, causing headaches in some people.
* Cold foods: Cold food, like ice cream, can cause headaches in some people. It’s more likely to occur if you are over-heated from exercise or hot temperatures. Pain, which is felt in the forehead, peaks 25 to 60 seconds and lasts from several seconds to one or two minutes. More than 90% of migraine sufferers report sensitivity to ice cream and cold substances.

9. Is Caffeine a Headache Treatment or a Headache Trigger?

Caffeine can be both beneficial and harmful for a headache sufferer. Caffeine is a common ingredient in many prescription and over-the-counter headache medications. Caffeine additives make pain-relievers 40% more effective in treating headaches. Caffeine also helps the body absorb headache medications more quickly, bringing faster relief.

While caffeine-containing medications can be beneficial, these medications, combined with consuming too much caffeine (coffee, tea, soft drinks or chocolate) from other sources, may make you more vulnerable to getting rebound headaches.

10. What Are Abortive Medications?

Abortive medications, when used at the first sign of a migraine, can stop the process that causes the headache pain. By stopping the headache process, abortive medications help prevent the symptoms of migraines including pain, nausea, and sound and light sensitivity. Some medications should not be used during a migraine aura; please follow the instructions of your doctor.

11. Do Children Outgrow Headaches?

Headaches may get better as your child gets older. The headaches may disappear and then return later in life. By junior high school, many boys who have migraines outgrow them, but in girls, migraine frequency increases because of hormone changes. Migraines are three times more likely to occur in adolescent girls than in boys.

12. Can Headaches Be Prevented?

Headaches can cause untold pain and suffering. But, you don’t have to resign yourself to be a headache sufferer. There are steps you can take to prevent headaches. Here are just a few ways to keep headaches at bay.

o Follow your treatment plan. Avoid taking medications that have not been ordered by your doctor.
o Reduce emotional stress. Take time to relax and take time away from stressful situations. Learn relaxation skills, such as deep breathing and progressive muscle relaxation.
o Reduce physical stress. Proper rest and sleep will allow you to deeply relax so you can face the stressors of the new day. When sitting for prolonged periods, get up and stretch periodically. Relax your jaw, neck and shoulders.
o Exercise regularly. Get at least 20 minutes of exercise three times a week. But, don’t over do it!
o Keep a regular routine. Eat meals and snacks at about the same times every day, and get enough sleep at night.
o Quit smoking. Smoking can trigger headaches and make any headache, especially cluster headaches, worse. Ask your doctor for information about smoking cessation programs in your community.
o Seek help when you are unable to cope. Talk to a friend, family member, religious or health care professional if your problems are getting to you.
o Know your headache triggers. Keep a headache diary to keep track of what triggers your headaches and avoid these triggers in the future.
o Preventive therapy. Women who often get headaches around their menstrual period can take preventive therapy when they know their period is coming.

Additional information about migranes and headaches

Are Migraines Hereditary?

Yes, migraines have a tendency to run in families. Four out of 5 migraine sufferers have a family history of migraines. If one parent has a history of migraines, the child has a 50% chance of developing migraines, and if both parents have a history of migraines, the risk jumps to 75%.

Can Migraines Be Prevented?

* Yes. You can reduce the frequency of your migraine attacks by identifying and then avoiding migraine triggers. You can keep track of your headache patterns and identify headache triggers by using a headache diary.
* Recalling what you ate prior to an attack may help you identify chemical triggers.
* Stress management and coping techniques, along with relaxation training, can help prevent or reduce the severity of the migraine attacks.
* Women who often get migraines around their menstrual period can take preventive therapy when they know their period is coming.
* Migraine sufferers seem to have fewer attacks when they eat on a regular schedule and get adequate rest.
* Regular exercise — in moderation — can also help prevent migraines.

Can Allergies Cause Headaches?

It is a misconception that allergies cause headaches. However, allergies can cause sinus congestion, which can lead to headache pain. If you have allergies, the treatment for your allergy will not relieve your headache pain. The two conditions generally must be treated separately. See your doctor to ensure proper treatment.

What Are Some Techniques I Can Use to Relax?

Below are a few relaxation exercises. But first, be sure that you have a quiet location that is free of distractions, a comfortable body position, and a good state of mind. Try to block out worries and distracting thoughts.

o Rhythmic breathing: If your breathing is short and hurried, slow it down by taking long, slow breaths. Inhale slowly then exhale slowly. Count slowly to five as you inhale, and then count slowly to five as you exhale. As you exhale slowly, pay attention to how your body naturally relaxes. Recognizing this change will help you to relax even more.
o Deep breathing: Imagine a spot just below your navel. Breathe into that spot, filling your abdomen with air. Let the air fill you from the abdomen up, then let it out, like deflating a balloon. With every long, slow exhalation, you should feel more relaxed.
o Visualized breathing: Find a comfortable place where you can close your eyes, and combine slowed breathing with your imagination. Picture relaxation entering your body and tension leaving your body. Breathe deeply, but in a natural rhythm. Visualize your breath coming into your nostrils, going into your lungs and expanding your chest and abdomen. Then, visualize your breath going out the same way. Continue breathing, but each time you inhale, imagine that you are breathing in more relaxation. Each time you exhale imagine that you are getting rid of a little more tension.
o Progressive muscle relaxation: Switch your thoughts to yourself and your breathing. Take a few deep breaths, exhaling slowly. Mentally scan your body. Notice areas that feel tense or cramped. Quickly loosen up these areas. Let go of as much tension as you can. Rotate your head in a smooth, circular motion once or twice. (Stop any movements that cause pain!) Roll your shoulders forward and backward several times. Let all of your muscles completely relax. Recall a pleasant thought for a few seconds. Take another deep breath and exhale slowly. You should feel relaxed.
o Relaxing to music: Combine relaxation exercises with your favorite music in the background. Select the type of music that lifts your mood or that you find soothing or calming. Some people find it easier to relax while listening to specially designed relaxation audio tapes, which provide music and relaxation instructions.
o Mental imagery relaxation: Mental imagery relaxation, or guided imagery, is a proven form of focused relaxation that helps create harmony between the mind and body. Guided imagery coaches you in creating calm, peaceful images in your mind — a “mental escape.” Identify your self-talk, that is, what you are saying to yourself about what is going on with your illness. It is important to identify negative self-talk and develop healthy, positive self-talk. By making affirmations, you can counteract negative thoughts and emotions. Here are some positive statements you can practice.
o Let go of things I cannot control.
o I am healthy, vital, and strong.
o There is nothing in the world I cannot handle.
o All my needs are met.
o I am completely and utterly safe.
o Every day in every way I am getting stronger

In order to receive proper treatment, a correct diagnosis of your headaches must be made. To properly diagnose the cause(s) of the headaches, your doctor will first take a headache history.

Headache History

The most important part of your doctor’s evaluation of your headaches is what’s called the headache history. It is important to describe your headache symptoms and characteristics as completely as possible. Your headaches can be better diagnosed if you tell your doctor:

· How old you were when the headaches started
· How long you have been experiencing them
· If you experience a single type of headache or multiple types of headaches
· How often the headaches occur
· What causes the headaches, if known (for example, do certain situations, foods or medications trigger the headaches?)
· Who else in your family has headaches
· What symptoms, if any, occur between headaches
· If your school or work performance has been affected by the headaches

It is also important to tell your doctor how you feel when you get a headache and what happens when you get a headache, such as:

· Where the pain is located
· What it feels like
· How severe the headache pain is, using a scale from 1 (mild) to 10 (severe)
· How long the headache lasts
· If the headaches appear suddenly without warning or with accompanying symptoms
· What time of day the headache usually occurs
· If there is an aura (changes in vision, blind spots or bright lights) before the headache
· What other symptoms or warning signs occur with a headache (such as weakness, nausea, sensitivity to light or noise, appetite changes, changes in attitude or behavior)
· How frequent you get headaches

You should also tell your doctor if you’ve been treated in the past for headaches and what medications (both prescribed and over-the-counter) you have taken in the past and what medications are currently being taken. Don’t hesitate to list them, bring the bottles, or ask your pharmacist for a printout.

Studies performed by other doctors who may have evaluated your headaches in the past, including X-rays and other imaging tests are also very important — you should bring these to your appointment as well. This may save time and repetition of tests.

Physical and Neurological Examinations

After completing the headache history portion of the evaluation, the doctor will perform a complete physical and neurological examination. The doctor will look for signs and symptoms of an illness that may be causing the headaches, such as:

· Fever or abnormalities in breathing, pulse, or blood pressure
· Infection
· Nausea, vomiting
· Changes in personality, inappropriate behavior
· Mental confusion
· Seizures
· Loss of consciousness
· Excessive fatigue, wanting to sleep all of the time
· High blood pressure
· Muscle weakness, numbness or tingling
· Speech difficulties
· Balance problems, falling
· Dizziness
· Vision changes (blurry vision, double vision, blind spots)

Neurological tests focus on ruling out diseases of the brain or nerves that may also cause headaches, such as epilepsy or multiple sclerosis. Some of the tests may also look for a physical or structural abnormality in the brain that may cause your headache, such as:

· Tumor
· Abscess (an infection of the brain)
· Hemorrhage (bleeding within the brain)
· Bacterial or viral meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
· Pseudotumor cerebri (increased intracranial pressure)
· Hydrocephalus (abnormal build-up of fluid in the brain)
· Infection of the brain such as meningitis or Lyme disease
· Encephalitis (inflammation and swelling of the brain)
· Blood clots
· Head trauma
· Sinus blockage or disease
· Blood vessel abnormalities
· Injuries
· Aneurysm (an outpouching of the wall of a blood vessel that can leak or rupture)

Psychological Evaluation

An interview with a psychologist is not a routine part of a headache evaluation, but may be done to identify stress factors triggering your headaches. You may be asked to complete a computerized questionnaire to provide more in-depth information to the doctor.

After evaluating the results of the headache history, physical examination, neurological, and psychological examination, your doctor should be able to determine the type of headache you have, whether a serious problem is present, and whether additional tests are needed. Possible additional tests you may be given include diagnostic tests.

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What is tension headache

Most important and common for vascular headache: the pulse of the same show with the pulsating pain or cramping. Bow, heat, strength, coughing or headaches, etc. will increase. Examination showed temporal artery uplift, pulsatility enhanced compression can reduce headaches.

Most of the causes of tension or anxiety induced, but also secondary to vascular headache or facial lesions headache, sometimes for head and neck myositis, or cervical muscle strain caused by cervical spondylosis.

The result of the head and neck muscles due to the continued contraction, mostly former head, or the whole head and neck pillow continuing Duntong.

Inspection should give prominence to key points, according to history-taking materials to the maximum extent possible to consider one or more of certain kinds of disease, first of all, be inspected as soon as possible, certain positive or negative diagnosis.
After a clear cause headache, and sometimes also need further examination, which is due to:

① headache may be more than one cause, such as migraine patients susceptible to hypertension; headache after traumatic brain injury in addition to neurasthenia performance, but also there are other types of mergers or intracranial complications of a headache.

② a headache can be the cause of secondary causes another headache. If sinusitis can be induced supraorbital neuralgia, may be secondary to otitis media, such as intracranial abscess. Clinical should be vigilant.

How to treat:

First of all, is to actively prevent and treat the disease. In addition to symptomatic treatment can be used outside of morphine analgesia drugs, such as various antipyretic analgesics, under clothes or short-term illness Dayton 2-3 times / d taking it seriously, in low doses can be codeine, or Rotundine Dihydroetorphine such. Can be used, as appropriate, increase or stability of various tranquilizers, anxiety, irritability Youyi. Depression performance, plus antidepressants. Psychiatry reference can be more than handouts. In the treatment, can also be a headache for the mechanism, for example:

① correct intracranial pressure: high intracranial pressure, such as giving dehydration, diuretics low intracranial pressure, such as intravenous fluid given low.

② vascular contraction and expansion: If migraine attack, the use of lysergic early preparations. Category of non-vascular migraine headache, common compound containing caffeine antipyretic analgesics, such as the APC, Suomi-Mig-to-ling, etc. to improve vascular tone.

③ relaxation of the muscle contraction: apply to muscle contraction headache, such as massage, heat, pain points novocaine closed, and so on, or use of weak stability and efficiency such as stability, tranquility, and so on, not only help relax the muscles and also help to lift the spirit tension.

④ suffering from the closure of the cranial nerve table: Table for cranial neuralgia. ⑤ “update” of the disease cerebrospinal fluid: after subarachnoid hemorrhage as severe headache can be stable condition after the situation is not high intracranial pressure, as appropriate, released bloody cerebrospinal fluid 5 ~ 10 ml, or oxygen injection contour, in an effort to CSF Absorption “update”, and often can quickly ease the headache. This method also applies to serous meningitis headache.

Several more common headache again on the specific control methods:

1. Migraine: an early attack one of the following methods used analgesics: Oral ergotamine 0.1 to 0.2 g of caffeine, such as null and void after the half-hour service can be further 0.1 g day total of not more than 0.6 g. Intramuscularly lysergic new base 0.2-0.5 mg, null and void when one hour after the repeat. Intramuscular anisodine pH 4-5 mg or slow intravenous 2-6 mg (50% glucose Add 40 ml). 0.5% novocaine subcutaneous closed around the expansion of the temporal artery, and so on. Arteriosclerosis, heart and brain or peripheral vascular disease, as well as pregnancy Jiyong ergot preparation. Intermittent period can be used to prevent the onset of Oryzanol (20-30 mg), propranolol (10-20 mg), anisodine pH (1-4 mg) or Mefenacef-啶(0.5-1 mg), three / d. Also taking ergotamine butanol amide (0.5 mg first dose, and gradually increased to 1-2 mg, 2 times / d, not more than six months, with the taboo of ergotamine), anisodine pH (1-4 mg), Mefenacef-啶(0.5-1mg), three / d. Puerarin films, Chuanxiong injection, Effects of Chinese Herbal Medicine, intravenous 0.5% novocaine (10 ml each, a total of 20-30), but also have a certain effect. On the longer course, frequent seizures, drug therapy ineffective and temporal artery dilated serious patients, as appropriate, may also try superficial temporal artery ligation.

2. Custer headache: attack can be used ergot preparation. Intermittent period for the drug can be tested, or prednisone 30 mg Leighton served for three consecutive days to 5-20 mg, once a day or every other day, three times to stop.

3. Neck migraine: cervical traction, expansion at the same time taking drugs or Blood Circulation vascular medicine and the treatment of carotid the coexistence of thoracic nerve root inflammation. Stellate ganglion trial can be closed. Conservative treatment fails and serious symptoms, can be considered for removal of the vertebral joints hooks.

4. Muscle contraction headache: massage, heat, electricity, as well as taking therapy excited stability, and meprobamate, such as muscle relaxants and sedatives. Tenderness in the muscles can also point to 2% novocaine 1-2 ml closed. Acute cervical muscle strain injuries can be caused cortisone acetate, 1 ml (plus 1% increase due to slavery Dover 1-2 ml) closed. Hyperplasia due to cervical spine injury caused or should increase cervical traction, plus neck and entrusted to consolidate traction effect.

5. Neuritis headache: the principle of the state neuritis treatment, in the supraorbital notch, “wind pools” Point and other places several times with 2% increases for Merino Dover 0.5-1 ml (or accession Vi.t B1 50mg or Vit.B12 100 μ g) closed, or with a 0.5 ml ethanol closed. Oral phenytoin or carbamazepine also an effective analgesic. Hyperplasia of the cervical spine caused by the greater occipital neuralgia should be used cervical traction.

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Background: The International Headache Society (IHS) began developing a classification system for headaches in 1985. Finalized in 1988, this system includes a tension-type headache category, further defined as either episodic or chronic. Headache categories also are defined by whether they are associated with pericranial muscle disorders.

Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs.

Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.

Tension-type headache is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the IHS intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology.

Pathophysiology: Both muscular and psychogenic factors are believed to be associated with tension-type headache.

Frequency:

* In the US: Headache is the ninth most common reason for a patient to consult a physician. Physicians classify 90% of headaches reported to them as muscle contraction or migraine headaches.

* Internationally: No literature suggests that headache frequency is different in other regions of the world.

Sex: A female preponderance exists.

Age: All ages are susceptible, but most patients are young adults.

* Approximately 60% of headache onset occurs in those older than 20 years.
* Headache onset is unusual in those older than 50 years.
* In elderly patients, the practicing physician should never assume that headache onset is due to benign causes, such as tension-type headaches, until pathologic etiologies are explored.

History: Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.

* IHS diagnostic criteria for tension-type headaches states that 2 of the following characteristics must be present:

o Pressing or tightening (nonpulsatile quality)
o Frontal-occipital location
o Bilateral - Mild/moderate intensity
o Not aggravated by physical activity

* Tension-type headache history is as follows:

o Duration of 30 minutes to 7 days
o No nausea or vomiting (anorexia may occur)
o Photophobia and/or phonophobia
o Minimum of 10 previous headache episodes; fewer than 180 days per year with headache to be considered “infrequent”
o Bilateral and occipitonuchal or bifrontal pain
o Pain described as “fullness,” “tightness/squeezing,” “pressure,” or “bandlike/viselike”
o May occur acutely under emotional distress or intense worry
o Insomnia
o Often present upon rising or shortly thereafter
o Muscular tightness or stiffness in neck, occipital, and frontal regions
o Duration of more than 5 years in 75% of patients with chronic headaches
o Difficulty concentrating
o No prodrome

* New headache onset in elderly patients should suggest etiologies other than tension headache.

Physical: The physical examination serves mainly to exclude the possibility of other headache causes.

* Vital signs should be normal.
* Normal neurologic examination
* Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted.
* Pain should not be elicited over temporal arteries or positive trigger zones.
* Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.
* Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.

Causes: Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction.

* Stress and/or anxiety
* Poor posture
* Depression

Lab Studies:

* Laboratory work should be unremarkable in cases of tension-type headache. Specific tests should be obtained if the history or physical examination suggests another diagnostic possibility.

* Head CT scan or MRI is necessary only when the headache pattern has changed recently or neurologic examination reveals abnormal findings. Such history or physical exam evidence would suggest an alternate cause of headache.

Prehospital Care: Most patients with severe headache should not receive opiate analgesics until the responsible physician can complete an appropriate history and neurologic examination.

Emergency Department Care:

* Ascertain that the patient is not overusing medication, shows no evidence of drug dependency, and is not depressed.

* If headache cause includes dental pathology, sinus disease, trigger points, or CNS pathology, initiate care to treat the specific cause.

While the emergency physician must be able to identify patients with serious headache etiology, more than 90% of patients in the ED have migraine, tension, or mixed-type benign headache. Therefore, providing symptomatic relief should be a priority.

Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, and occipital nerve blocks.

Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program.

Further Outpatient Care:

* Physical therapy for patients with headache includes warm and cold packs, ultrasound, and electrical stimulation.
* Regular exercise, stretching, balanced meals, and adequate sleep are part of a headache prevention program.
* Trigger point injections, occipital nerve blocks, or changes that improve posture may be used.

Deterrence/Prevention:

* Physical therapy
* Biofeedback and relaxation therapy
* Cervical traction
* Injection of trigger points

Complications:

* Undue reliance on nonprescription caffeine-containing analgesics
* Dependence on/addiction to narcotic analgesics
* GI bleed from use of NSAIDs
* Risk of epilepsy 4 times greater than that of the general population

Prognosis:

* Headache may become chronic if life stressors are not changed.
* Most cases are intermittent and do not interfere with work or normal life span.

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Overview of tension headache is the result of head and neck muscle sustained contraction, which leads to the contraction of this for three reasons :
- as anxiety or depression accompanied by the nervous
- as other reasons why the headache or pain in other parts of the body as a secondary symptom
- as the head, neck, shoulder girdle caused by bad posture.

Clinically the disease is extremely common in women, more than 30 years after onset, psychological treatment can often received good results.

A clinical performance:
- More headaches at two places and pillow, neck, and was persistent pain that patients often v. head stun flu and heavy pressure flu, not associated with nausea and vomiting.
- Headache can wake up in the morning or get up there soon after, or a full day, gradually increasing unchanged patients often claimed not to ease headaches over the years.
- Some migraine patients and coexist.
- Some patients have “air pillows” levy.

A diagnosis:
- Headache after more than 30 years, located in two places and pillow, neck, and was persistent pain. and the continuing headache for the main character.
- Some migraine patients and coexist.
- Some patients have “air pillows” sign.
- Remove brain tumors, hypertension, such as epilepsy and glaucoma caused by the headache.

Treatment:
1. Stage : control headache.
2. Remission : preventive attack.

Treatment of the disease is the key to preventing attacks, psychological examination and psychological treatment is extremely important, in psychological treatment, supplemented by frame on the basis of the limited drug treatment. An auxiliary inspection. For newly diagnosed patients with a headache check box should be selected subject to “A”, Some patients may choose to limit check box “B” of one or two. 2. For insubstantial or can not be ruled out intracranial vascular malformation and headache epilepsy patients should use restrictions check box “C” of 1 or 2.

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