milder in comparison to secondary headaches and cranial/ facial neuropathies. In addition, primary headaches manifest episodically, whereas secondary headaches tend to be continuous, sometimes increasing in intensity with time. Cranial Table 1: A Comparison of the classification of headaches Primary
neuropathies, facial pain, and other headaches share the characteristic of episodic attacks with primary headaches but are extremely painful and short in duration. A full comparison of the three classifications in shown in Table 1.
Cranial Neuropathies, Facial Pain, and Other Headaches
Secondary
Cause
• Muscle tension. • Altered chemical activity in the brain. • Inflammation.
• Disease. • Structural change. • Medication overuse.
• Compressed nerve. • Nerve inflammation. • Infection of a nerve.
Pain description
• Dull ache. • Throbbing. • Severe pain. • Intermittent. • Varies.
• Severe. • Unrelenting. • Sudden onset.
• Sharp. • Stabbing. • Piercing. • Short. • Episodic.
Frequency
• Continuous. • Progressively worsens.
Source: International Headache Society, 2016
HEADACHE TYPES
Nearly 400 types of headaches are classified in the ICHD-3 beta. Most of these fall under a broader type of headache but specify symptoms. For instance, a migraine with aura is one class of migraine where motor symptoms, such as muscle weakness, remain up to 72 hours after the migraine has ended. This is further divided into another class called migraine with typical aura, which possesses all the same attributes of a migraine with aura, except once the migraine has ended, all symptoms dissipate completely. For the primary headache category, the three common types are tension-type, migraine, and cluster headaches. Cervicogenic, post- traumatic, and thunderclap headaches are the most Tension-type headaches It is almost guaranteed a massage therapist will come across cases of tension-type headache. They are the most prominent form of cephalalgia afflicting people, mostly women, at an estimate of 1.6 billion cases per year. Sometimes called pressure headaches , tension- type headaches are depicted as a constant vice-like band spanning the forehead that may include the occipital and cervical regions. This form of headache is by far the mildest of all. Most people carry on with their regular daily activities during an episode, but as the day progresses, the intensity of pain may increase from mild to moderate (Wikipedia, 2017c). Other symptoms characteristic of tension-type headaches include a gradual onset, bilateral pain, and a dull ache and pain concentrated at either the temples or eyebrows. Physical and emotional stress often produces an attack through excessive contraction of the muscles of the head and neck (Johns Hopkins, 2017a). Examples of emotional stress triggers are anxiety and depression. Physical stressors include fatigue, dehydration, teeth clenching, poor posture, prolonged periods staring at a computer, or sleeping in an awkward position (DeLaune, 2008). The ICHD-3 beta requires the following measures be met to qualify a headache as tension-type: 1. An average of fewer than 12 days per year of headache attacks. 2. Pain that persists anywhere from 30 minutes up to 7 days. 3. Pain that meets at least two out of the four listed characteristics: ○ Located on both sides of the head. ○ Pressing or squeezing. ○ Mild to moderate intensity. ○ Not worsened through physical exertion, such as walking or climbing stairs. 4. Must meet both of the following: ○ Not accompanied by nausea or vomiting.
important for massage therapists to be familiar with from the secondary headache category. Trigeminal neuralgia and occipital neuralgia types from the cranial neuropathies, facial pain, and other headaches category are the only two necessary with which to be knowledgeable (International Headache Society, 2016). It is not necessary for a massage therapist to be familiar with the minutiae of cephalalgia; this is not in her scope of practice to diagnose. Recognizing and understanding the major headache types under each classification is all that is essential, especially those that are positively influenced by massage. ○ May be accompanied by sensitivity to bright lights or loud sounds, but not both. Sometimes this is confused with a mild migraine with aura. (International Headache Society, 2016; Wikipedia, 2017e). Another headache that mimics tension-type symptoms is medication overuse headache. Classified as a secondary headache, this form of cephalalgia arises from a prolonged use of pain medications. Ironically, the medication is often taken to relieve headache pain, yet over time, the body becomes hypersensitive in response so that the medication no longer has an effect, and a chronic headache remains (Wedro, 2017). If a patient experiences more than 15 days of episodes in a month for at least three consecutive months, it is possible he is suffering from a chronic tension-type headache; the situation should be viewed as a warning sign of a possible hidden disease. Only 1% to 3% of the adult population truly suffers from this form of headache (International Headache Society, 2016; WHO, 2016). The best way to decipher another condition causing chronic tension pain is if the headache occurred in close relation to the diagnosis of a condition known to cause headaches. It is still considered a primary headache regardless of a secondary condition causing the pain. What is important to know with chronic tension-type headaches is that chronic tension cephalalgia is caused within the brain or spinal cord, whereas infrequent tension cephalalgia results from peripheral mechanisms (International Headache Society, 2016). This is significant for the massage practitioner to understand for the patient’s treatment plan. An example of peripheral mechanisms is trigger points in the suboccipitals, upper trapezius, sternocleidomastoid, masseter, or temporalis muscles. These send afferent input, or signals, to the brain where it is processed and then interpreted as pain (DeLaune, 2008; Wikipedia, 2017e). A central mechanism could
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