Overlapping with depression and anxiety A strong interaction between headache and depression and anxiety has been established (Wei et al., 2016). Comorbidity of depression or anxiety may cause risk for stronger intensity, longer duration, and more recurrent frequently occurring headaches. Shared biological pathways and norepinephrine and serotonin neurotransmitters are one possible explanation for the cooccurrence of headaches, depression, and anxiety (Wie et al., 2016). Side effect of medication The introduction of any new drug can be associated with the new onset of headache and can be considered a sign of incompatibility with that drug (Do et al., 2019). When reviewing a client’s medication list, special attention should be paid to the addition of any new medications. Allergen or toxin (environmental or food) Many different environmental factors and types of food can be Overuse of medications to manage primary headache symptoms is considered a common problem (Vandenbussche, 2018). The use of analgesics to manage the pain and disability related to headache syndromes such as migraine and tension-type headaches is justified, though it is recognized that frequent use of analgesics promotes headache chronicity. Medication overuse headache is recognized by the International Classification of Headache Disorders (3rd ed.; ICHD-3). The criteria for this diagnosis are: 1. Headache occurring on ≥15 days/month in a patient with a preexisting headache disorder. 2. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache. sources of headaches for specific individuals. Overuse of medication (analgesic rebound) 3. Not better accounted for by another ICHD-3 diagnosis. Medications listed in the ICHD-3 criteria for possible overuse include ergotamine, triptan, acetaminophen, nonsteroidal anti- inflammatory drugs (NSAIDs), aspirin, and opioids. Use of multiple headache medications is also noted (Vandenbussche et al., 2018). Although a complete understanding of the pathophysiology of medication overuse headaches does not exist, animal studies have shown changes in multiple physiological processes in the central nervous system after repetitive use of analgesics (Vanderbussche et al., 2018). Caffeine use or withdrawal Chronic consumption of caffeine promotes a pro-nociceptive state of cortical hyperexcitability (Espinosa Jovel et al., 2017). As such, caffeine can trigger or intensify a headache. Caffeine overuse that can cause headaches is defined as >450 mg/day (Espinosa Jovel et al., 2017). Withdrawal from caffeine can also cause headaches. According to the International Classification of Headache Disorders, the following diagnostic criteria should be assessed to determine if a headache is due to caffeine withdrawal: A. Headache fulfilling criterion C. B. Headache following an interruption in regular consumption of caffeine in excess of 200 mg/day for more than two weeks. C. Evidence of causation demonstrated by both of the following: a. Headache developing within 24 hours after last caffeine intake. b. Either or both of the following: i. Headache is relieved within one day. ii. Headache is resolved within seven days after total caffeine withdrawal. D. Not better accounted for by another ICHD-3 diagnosis. Postdural puncture A postdural puncture headache usually occurs within 5 days of a dural puncture. It is typically worse when the patient is upright and improves when supine (Weji et al., 2020). In most cases,
postdural puncture headaches resolve within one week (Kwak, 2017). Hantavirus Hantavirus is a rare pulmonary infectious disease caused by rodents. Headache, along with fever and chills, and muscle aches and pains, is one of the common symptoms (Hantavirus Pulmonary Syndrome - Symptoms and Causes, 2022). Paget’s disease (when the skull is affected) Paget’s disease is focal remodeling of bone that affects 1% to 2% of people over 55 years of age, mainly white men (Evangelatos et al., 2017). The head bones are frequently involved, and patients may suffer from deformity as well as headache and neurological deficits. Headache in Paget’s disease is characterized by severe headaches typically located in the occipital area (Evangelatos et al., 2017). Hypoglycemia Hypoglycemia, or low blood sugar, has been shown to cause both general headaches and migraine headaches (Silver, 2022). Fibromyalgia Fibromyalgia is a common comorbidity associated with headaches (Caponnetta et al., 2021). It is thought this might be related to the presence of central sensitization that is seen with this condition (Siracusa et al., 2021). Temporomandibular joint dysfunction Temporomandibular disorders and headache often occur together, and the incidence of headache in patients with this diagnosis is between 48% and 77% (Di Paolo et al., 2017). According to Byun et al. (2020), this phenomenon is related to the fact that both conditions have a common nociceptive system. Neurons involved in migraine headaches are linked to the first branch of the trigeminal nerve and to the trigeminocervical complex, and those involved in temporomandibular disorders are linked to the neurons of the third branches of the trigeminal nerve. Di Paolo et al. (2017) also state that central sensitization could play a role. The purpose of this long list of possible systemic origins of headaches is threefold: (1) to help the therapist understand the complex nature of headaches, (2) to show how important it is to thoroughly review the patient’s medical history and to delve deep into understanding the nature of their symptoms, and (3) to help the therapist understand how important it is to refer the patient to a medical specialist when physical therapy intervention is not effective in eliminating their headache symptoms. Self-Assessment Quiz Question #10 The characteristics of headache related to COVID-19 include:
a. Mild to moderate, unilateral, and pulsating. b. Moderate to severe, bilateral, and pulsating. c. Mild to moderate, supraorbital, and pressing. d. Mild to moderate, occipital, and pressing.
Self-Assessment Quiz Question #11 A patient presents to your clinic as a walk-in with a severe headache that came on earlier in the day while they were running. The Ottawa Subarachnoid Hemorrhage Rule can be used to identify subarachnoid hemorrhage in people with acute headaches. According to this rule, which of the following accompanying findings might lead you to suspect subarachnoid hemorrhage?
a. Age 40 years or older. b. Neck pain and stiffness. c. High blood pressure. d. All except c.
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