are forward head posture, rounded shoulders, kyphosis, and augmented cervical lordosis. These alterations place strain on the shoulder joint leading to upper trapezius and levator scapulae hypertonicity, which then creates hypertonicity in the pectoralis muscles, elevating the shoulders and pulling them forward. As a result, the lower trapezius, rhomboids, and serratus anterior muscles weaken, and the deep cervical flexors (especially longus capitis and longus colli) on the anterior of the body weaken in response (Frank et al., 2010). This postural imbalance eventually leads to dysfunction in the cervical spine, particularly at the atlantoaxial joint, but may also occur at the C4 and C5 articulation and is customarily seen as bone spurs. Irritation of surrounding structures from a bone spur could cause cervical radiculopathy or osteochondritis (Frank et al.; Physiopedia 2017), both of which were previously mentioned as causes for CGH. Another complication seen with UCS is an overactive SCM. It is common to find a significant discrepancy in length and strength between the right and left SCM in individuals with neck pain. This is likely caused by the weakness of the deep cervical flexors yet results in the SCM aiding in respiration and contributing to further inhibition of the diaphragm, which then reinforces cervical dysfunction with each breath (Frank et al., 2010). Once again, the clinical presentation for CGH includes unilateral pain beginning from the neck or eye that is worsened with neck movement, often lacerating pain, and may be accompanied by stiffness or a locked neck. Cervical range of motion is limited, and the upper three cervicals are tender upon palpation (International Headache Society, 2016; Physiopedia, 2017). With this in mind, the massage practitioner can employ several procedures to assess the patient for probable CGH pain. Post-traumatic headaches Post-traumatic headaches pose a complexity. There are no distinguishing features from tension-type headaches or migraines or even CGH; in fact, quite often a post-traumatic headache becomes a CGH because the trauma often creates dysfunction in the cervical spine (International Headache Society, 2016). Because of the overlap in characteristics, a history of recent injury is key to recognizing a post- traumatic headache. The two prominent injuries implicated in this type of cephalalgia are whiplash and concussions. Whiplash is most often associated with motor vehicle accidents but may also transpire from a fall or bicycle accident. In either of these situations, vertebral or soft tissue injury results from a sudden hyperextension of the head, followed by hyperflexion brought about by the sudden impact of a car or other moving object. More often than not, this presents from a rear-end collision; however, it is not unusual to occur from the side. On the other hand, a concussion is caused by blunt force trauma resulting from an impact to the head as often seen in contact sports, such as football or boxing According to the ICHD-3 beta, the general diagnostic criteria for acute headache in the aftermath of a traumatic injury to the head is as follows: 1. Any headache satisfying Criteria 2 and 4. 2. Recent history of traumatic injury to the head. 3. Development of a headache within seven days of one of the following: ○ Injury to the head. ○ Regaining consciousness after a head injury. ○ Aborting the use of medication that would inhibit the ability to sense a headache after an injury to the head. 4. Either of the following: Thunderclap headache A severe and sudden headache that appears out of nowhere and reaches maximum intensity within seconds is the reason the term thunderclap headache was first used in 1986 (Wikipedia, 2017a). This type of secondary headache may occur for several reasons,
Once it is determined that the outlined criteria are met, the first assessment is postural observation. Characteristic UCS posture will likely be present to some degree. Next, a quick single leg stance will show the patient needing to reposition the head to assist with balance. After that, observing the patient’s gait will show an excessive use of the cervical muscles. The next stage involves assessing the patient’s movement pattern. This is accomplished through two different movements. The first, flexion. A patient exhibiting neck dysfunction will bring his or her chin forward during flexion of the head, which affirms weakness of the deep flexor muscles and hypertonicity of SCM. The second movement pattern to test is shoulder abduction. From a seated position with elbows bent, the patient abducts the arms 90 degrees. The shoulder elevated before 60 degrees of abduction indicates instability likely stemming from an overactive upper trapezius and levator scapula (Frank et al., 2010). The final assessment is the flexion-rotation test, which must occur when the patient is not experiencing neck pain. For this test, the patient lies supine while the therapist guides his head to end range of motion for cervical flexion. While supporting the head in this position, the therapist then passively rotates the head while receiving feedback from the patient when pain is felt, at the same time noting any restrictions. A positive result is achieved when range of motion is 34 degrees or less (Physiopedia, 2017). Even though re-education and restrengthening of weakened structures at or around the cervical region lies outside a massage therapist’s scope of practice, trigger point therapy and other soft tissue work is important to overcoming or simply managing CGH. ○ Headache that goes away by the end of three months after experiencing an injury to the head. ○ Headache that is still present within three months of experiencing injury to the head. (International Headache Society, 2016) Depending on the severity of the impact, other symptoms may present in addition to the headache pain: dizziness, sleep disturbances, fatigue, inability to concentrate, impaired memory, and slowed thought or speech processing. In cases of severe jolting or multiple concussions, a change in personality can also occur (International Headache Society, 2016). Typically, a headache that develops post-trauma is considered acute during the first three months. Beyond that time, it is relabeled as persistent. An area of obscurity in the diagnostic criteria is the requirement that the post-traumatic headache appear within seven days after the injury or after consciousness is regained. Some professionals refute this with evidence of patients having developed a headache outside the initial seven-day time frame (International Headache Society, 2016). Lacking sufficient data to necessitate a change to the criteria, it is then left to the judgment of the patient’s health care practitioner to determine whether the condition can be classified under this headache type until research overwhelmingly supports altering the standards. In the meantime, massage has increasingly become widely accepted by insurance providers in the treatment of whiplash injuries, making it imperative for therapists not only to recognize post-traumatic headache characteristics but also to ensure integrity in reporting the extent of the impact on the quality of life the headache has on the patient. Unfortunately, it is commonplace for some patients to claim headache pain pending litigation, followed by immediate resolution of symptoms once a settlement has been reached (International Headache Society, 2016).
most of which are vascular in nature and all require immediate emergency attention. Unlike cluster headaches, which present as an extremely piercing pain in and around one eye, a thunderclap
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