Tension-type headaches are generally caused by muscle tension that, over time, can alter the pain processing mechanism of the brain (Wikipedia, 2017c). Migraines and cluster headaches are neurological disorders to begin with that affect muscle tension as a secondary response or condition (International Headache Society, 2016). For migraine sufferers, this presents as a possible increase in trigger point activity (DeLaune, 2008). People afflicted with cluster headaches experience anxiety in anticipation of the next attack that usually results in excess tension of the muscles of the head and neck (Wedro, 2017).
The type of pain experienced by primary headaches occurs unilaterally with the possibility of bilaterally in some cases and generally described as mild to moderate, with cluster headaches being the most localized and severe (International Headache Society, 2016). Of the three headache types, tension-type is the only one indicated for massage during the acute phase of an attack. Migraine and cluster headache sufferers will benefit from massage therapy when in remission. Table 2 compares the three main primary headaches.
Table 2: Three Main Primary Headaches Headache Type Demographic Cause
Massage Indicated
Signs and Symptoms • Mild, dull ache. • 30 minutes to 7 days. • Bilateral. • Light sensitivity OR
Tension-type Women more than men
• Primary mechanism: trigger points. • Central mechanism:
Yes.
Desensitization of the spinal cord or brainstem.
• Auditory sensitivity, but not both. • Not aggravated by physical activity. • Throbbing pain (moderate to severe). • Duration 4 to 72 hours. • Unilateral but may become bilateral. • Light and auditory sensitivity. • Aggravated by any movement. • Nausea/vomiting. • Auras. • Several times a month to several times a year. • Triggers. • Severe stabbing pain. • Duration 15 minutes to 3 hours. • Unilateral. • Affects eye. • Pacing. • Red eye, runny nose. • Drooping eyelid. • Occurs in groups per day/week/month.
Migraine (with or without aura)
Women
• Unknown,
Contra-indicated during the acute phase.
neurological in origin.
Cluster headache
Men
• Unknown,
Contra-indicated during the acute phase.
neurological in origin.
Cervicogenic headaches Cervicogenic headaches (CGH) are a secondary headache type resulting from a dysfunction of the cervical spine that could have postural implications or be the result of degeneration of the upper cervical vertebrae (International Headache Society, 2016; Physiopedia, 2017). Although similar to chronic tension-type headaches and chronic migraines in regards to the areas affected by pain, CGH pain differs in origin by starting from the back of the head or neck and then radiating to the front (International Headache Society, 2016). Another characteristic that separates CGH from the chronic primary headache types is the aggravation of pain when pressure is applied to the neck musculature or from head movement. The neck also may become locked up, producing headache pain and a limited range of motion (Physiopedia, 2017). Following are the criteria for diagnosis of CGH in the ICHD-3 beta: 1. Headaches that meet the requirements outlined in 3. 2. Evidence of dysfunction in the cervical spine or ligaments, musculature, or discs known to cause headaches. 3. Evidence the headache pain originates from at least two of the following: ○ New headache that cultivates close to the time a known cervical disorder also develops. ○ Headache pain is reformed by improvement of the causative cervical disorder. ○ The range of motion of the neck decreases and is implicated in aggravating headache pain. ○ The headache goes away following the injection of a nerve block. (International Headache Society, 2016)
As stated earlier under the anatomy section, the C1 and C2 articulation (atlantoaxial joint) is responsible for the majority of head movement, so a dysfunction of this joint, including discs and ligaments, usually causes CGH pain (Physiopedia, 2017). The articulation between C2 and C3, however, has also been implicated as a cause of CGH pain (International Headache Society, 2016). Spondylosis , commonly known as disc degeneration, or osteochondritis, inflammation of the cartilage or bone in a joint, are two possible reasons for joint dysfunction in a case of CGH (Physiopedia, 2017). Imaging is required to verify the presence of either of these conditions and their possible contribution to headache pain as explained in Criterion 2. Another condition attributed to CGH is upper cervical radiculopathy. This is identified as a pinched nerve in the upper neck region. Researchers have found a mechanism in the upper cervical spinal cord where spinal nerves C1, C2, and C3 combine with the trigeminal nerve to form the trigeminocervical nucleus. It is this connection that allows pain signals from the neck region to transfer and refer into the face via the trigeminal nerve. Consequently, pain signals from a pinched nerve in the upper cervical region refer to the face as well as the neck and arm (International Headache Society, 2016; Physiopedia, 2017). Postural imbalance is widely accepted as a causative factor in CGH pain, particularly because of upper crossed syndrome (UCS) (Physiopedia, 2016). Aside from presenting with trigger points in the same indicated muscles as seen with tension-type headaches, a person with CGH will also present with weak cervical flexor muscles, both of which indicate UCS. Other signs of UCS
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