neuralgia, the ICHD-3 beta requires the headache meet the following criteria: 1. Pain on one or both sides of the head that also meets Criteria 2, 3, 4, and 5. 2. Pain that follows the innervation path of the greater or lesser occipital nerves. 3. Pain fulfilling two of the three traits: ○ Episodic, brief sudden attacks. ○ Severe intensity. ○ Electric-like, sharp quality. 4. Pain resulting from both of the following: ○ Pain arising from harmless stimulation to the scalp or hair. ○ Either or both of the following: ■ Sensitivity at the area the nerve is located. ■ Trigger points at or along the C2 innervation path. As stated under Criterion 5, the best way to differentiate true occipital neuralgia from a migraine is if a nerve block administered to the area provides immediate relief (Gotter, 2017). Considering muscle tension is a probable cause for occipital neuralgia, massage therapy can play a key role in the treatment 5. Nerve block effectively aborts pain. (International Headache Society, 2016)
process. Mindfulness of scalp sensitivity must be taken into account, and patient communication must remain open when working in the suboccipital region. Likely, the patient will seek massage for this headache type after receiving a nerve block. It is during this time that palpation to the upper scalp is possible and the Brügger test can be used to assess whether suboccipital spasm is a primary or secondary condition (Dalton, 2017). Based on the concepts of Swiss neurologist Alois Brügger (1920–2001), who used a neurophysiological approach to explain symptoms, the Brügger test begins with the patient standing upright. The therapist places one hand on the patient’s forehead and lightly presses the thumb and index finger of the other hand into the suboccipital musculature. The therapist notes the degree of spasm and, while maintaining this position, asks the patient to sit down. Once seated, any decrease in spasm denotes the symptoms as a secondary condition to a functional or structural issue affecting posture that will need to be addressed in the treatment plan (Dalton, 2017). Cranial neuropathies, facial pain, and other headaches are quite rare, and often surgery is considered as a permanent management option (Gotter, 2017).
THE INTAKE PROCESS
Reading and understanding the differences between headaches is one skill; putting this knowledge to practice is quite another, especially with the overlap between primary and secondary headache types. Aside from the similarity in headache qualities, many patients come to the intake with several disadvantages leading to poor communication. The first is showing up in the midst of a headache attack, which will likely cause them to try to rush through the process. The other two obstacles to a proficient intake are that patients generally lack the ability to converse in medical lingo as and the tendency to self-diagnose (Diamond, 2015). An example of the first obstacle is often seen when a patient attempts to explain the location of his pain, noting the back of the head when actually meaning the upper neck. The second obstacle requires adept questioning by the therapist to objectively recognize the headache type. There are three stages to the intake process. The first stage is the assessment. This includes gathering as much information from the patient as possible, for instance, when the first headache was experienced, where the pain was located, and how long it lasted. (Fritz, 2015). After this is accomplished, the clinical reasoning stage is next. This point in the intake process involves the therapist looking over all the data collected and preparing a treatment plan. Finally, the justification stage concludes the process, with the therapist weighing the benefits of massage against possible harm from it and presenting the argument to the patient (Fritz). Being well versed in the signs and symptoms of the major headache types, in addition to contraindications, will help the therapist to expedite this procedure. Considering most primary headache types are diagnosed during the assessment stage (Diamond, 2015; International Headache Society, 2016), this is likely the most critical step. The goal for the therapist should be to spend this time listening for clues while being ready to guide the patient with specific questions to gain more information yet keeping the conversation unstructured enough that the patient feels comfortable to freely share her headache history (Diamond, 2015). Oftentimes when a person is able to speak openly, she will provide more information than in a question-and-answer situation. An example of this form of interview is a patient mentioning difficulty with sleeping in association with experiencing a headache. The therapist could then politely interject and ask for a clarification of the sleep disturbance: “Is it difficult to fall asleep because of the headache?” “Are you awakened by the headache?” (Diamond, 2015). The answers to these questions will help determine if a migraine, where
nausea and auras can make falling asleep challenging, or cluster headache that awakens sufferers from sleep is the more likely malady. Another advantage is the possibility of identifying a correlation between chronic headache attacks and medication usage. If the patient expresses a ritual of ingesting pain medication with each headache episode, there is a good chance the frequent attacks are a result of medication overuse. During an unstructured interview, the therapist can also collect data that will present a timeline as to possible triggers, such as emotional or physical stress in the case of tension-type headaches. A timeline can also indicate when a new headache type is experienced, suggesting a secondary headache. For some headache types, like migraines, it is common for sufferers to also experience tension-type headaches (International Headache Society, 2016). This is where paying attention to clues is imperative for proper guidance. A fragile situation to look for during an assessment is misdiagnosis. Regardless of where the diagnosis originated – from a physician or the patient himself – this can be a common occurrence. It is usually the result of miscommunication (Diamond, 2015). Migraines, for example, are notoriously diagnosed as sinus headaches for varied reasons (International Headache Society, 2016), so paying close attention for clues that reveal possible triggers or auras can help rectify the situation and produce proper treatment options for the patient. Understanding that diagnosis is out of the scope of practice for a massage therapist, referring the patient back to his physician equipped with the newly found information is the proper way to handle a suspected misdiagnosis. Phrasing a question is very important. Following are some examples of questions to ask a patient to gather facts while keeping the interview unstructured: 1. When was your first headache? 2. Did anything happen before your headache (stress, hormone change, injury)? 3. How frequently do you experience headaches? 4. How long does the pain last? 5. Do you take medication (aspirin/ibuprofen) for your pain? Is it effective? 6. Where do you feel your headache? 7. Does your head pain travel to the other side or remain on one side?
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