"WHICH Headache to Investigate, WHEN, and HOW?"

A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist's Perspective

PURPOSE OF REVIEW

Migraine is common and interventions to treat or manage it vary. Physical therapists possess a varied skill set that can assess and treat limitations related to migraine and its symptoms. Conservative and non-pharmacological examination and treatment techniques for migraine and headache management are reviewed in terms of efficacy and relevance in order to describe the physical therapist's abilities and clinical reasoning process when confronting a patient with migraine symptoms.

RECENT FINDINGS

A thorough examination is necessary to detect red flags and will reveal a person with migraine's biopsychosocial limitations to manage their symptoms. Strength, endurance, cervical mobility, and visual deficits are common in those reporting headaches and examination techniques, along with patient-reported outcome measures, can elicit objective data for re-assessment during an episode of care. Exercise interventions, manual therapy, biofeedback techniques, and vestibular therapy have become viable and efficacious non-pharmacological interventions in recent years to assist the patient with managing and mitigating their migraine symptoms, along with mindfulness-based exercises. A case study, with individualized treatment approaches based on examination findings, current evidence, and accrued expertise, demonstrates the clinical applicability of a physical therapist's multimodal approach to treating migraine. Psychologically- informed physical therapy with mindfulness-based approaches and biofeedback can help a patient gain more control over their symptoms and their body's response to head pain, while exercise and vestibular therapy can assist the system with recovery and adaptation from deficits related to migraine symptoms. A thorough examination, with an individually- tailored rehabilitation plan incorporating movement and mindfulness-based therapies, is recommended.

Imaging of Headaches due to Intracranial Pressure Disorders

Changes in intracranial pressure are a potentially serious etiology of headache. Headache secondary to changes in intracranial pressure frequently present with characteristic clinical features. Imaging plays a key role in the diagnosis and management of this category of headache. In this article, we will review the physiology, clinical presentation, and key imaging findings of major etiologies of changes in intracranial pressure resulting in headache including obstructive and nonobstructive hydrocephalous, idiopathic intracranial hypertension (IIH), and cerebrospinal fluid (CSF) leak.

Neuroimaging of Headache: Indications and Controversies

Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.

Headache in the Neurological Emergency Department—High Degree of Inadequate Documentation Calls for Structured Assessments

Headaches are a frequent reason for presentation to the emergency department (ED) and can pose a great challenge for the attending physicians. First and foremost, the distinction between a primary and secondary headache with potentially life-threatening implications can be difficult. Moreover, it often occurs that no specific headache diagnosis is made at discharge from the ED. Therefore, in this present retrospective cross-sectional study, all patients who presented to the emergency department of the Department of Neurology at Rostock University Medical Centre with the main symptom of headache between November 2013 and November 2016 underwent a neurological examination and the extent to which warning symptoms (“red flags”) for a secondary headache as well as symptoms necessary for a correct headache diagnosis according to the ICHD-3 classification were recorded and documented. We could show that documentation of red flags and clinical characteristics is inadequate and does not allow proper diagnostic categorization. To facilitate concise documentation and rapid decision making we suggest a structured and standardized form for documenting the headache history and red flags in the ED.

Evaluation of headache in patients with cancer

Headache is a common complaint and is often benign. When patients with cancer describe new headaches, it is important to ensure that there are no emergent or concerning etiologies, including metastatic disease. This review article details primary and secondary headaches. Red flags-the do-not-miss warning signs-are described. An initial approach to the evaluation, including suggestions for imaging, features to look for in a targeted examination, and when to request a consultation, is outlined. An overview of headache etiologies is described with a particular emphasis on the most common types: migraine and tension. The classification of headaches, based on criteria from the International Classification of Headache Disorders (3rd edition; beta version), is reviewed. Medications used for treatment, including newer biological agents, are described, and there are details about both abortive and preventive medication therapies. Suggestions for complementary and integrative therapies, some of which may be synergistic in treating other cancer symptoms, are outlined; they include mindfulness therapies, which are gaining traction in treating a variety of medical conditions. Readers should have an understanding of headache evaluation in patients with cancer and should know how to formulate a plan for a diagnosis. In addition, readers will gain familiarity with common treatments, both pharmacological and complementary/integrative.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Prevalence and factors associated with the use of primary headache diagnostic criteria by chiropractors

Background

The diagnosis of primary headaches assists health care providers in their decision-making regarding patient treatment, co-management and further evaluation. Chiropractors are popular health care providers for those with primary headaches. The aim of this study is to examine the clinical management factors associated with chiropractors who report the use of primary headache diagnostic criteria.

Methods

A cross-sectional survey was distributed between August and November 2016 to a random sample of Australian chiropractors who are members of a practice-based research network (n = 1050) who had reported ‘often’ providing treatment for patients with headache disorders to report on practitioner approaches to headache diagnosis, management, outcome measures and multidisciplinary collaboration. Multiple logistic regression was conducted to assess the factors that are associated with chiropractors who report using International Classification of Headache Disorders (ICHD) primary headache diagnostic criteria.

Results

With a response rate of 36% (n = 381), the majority of chiropractor’s report utilising ICHD primary headache diagnostic criteria (84.6%). The factors associated with chiropractors who use ICHD primary headache diagnostic criteria resulting from the regression analysis include a belief that the use of ICHD primary headache criteria influences the management of patients with primary headaches (OR = 7.86; 95%CI: 3.15, 19.60); the use of soft tissue therapies to the neck/shoulders for tension headache management (OR = 4.33; 95%CI: 1.67, 11.19); a belief that primary headache diagnostic criteria are distinct for the diagnosis of primary headaches (OR = 3.64; 95%CI: 1.58, 8.39); the use of headache diaries (OR = 3.52; 95%CI: 1.41, 8.77); the use of ICHD criteria improves decision-making regarding primary headache patient referral/co-management (OR = 2.35; 95%CI: 1.01, 5.47); referral to investigate a headache red-flag (OR = 2.67; 95%CI: 1.02, 6.96) and not referring headache patients to assist headache prevention (OR = 0.16; 95%CI: 0.03, 0.80).

Conclusion

Four out of five chiropractors managing headache are engaged in the use of primary headache diagnostic criteria. This practice is likely to influence practitioner clinical decision-making around headache patient management including their co-management with other health care providers. These findings call for a closer assessment of headache characteristics of chiropractic patient populations and for further enquiry to explore the role of chiropractors within interdisciplinary primary headache management.

Neuroimaging of Adults with Headache: Appropriateness, Utilization, and an Economical Overview

One of the most common reasons that a patient seeks out a health care provider for a neuroscience-related issue is headache. Not all patients can, or probably should, be imaged with headache. We must use an approach that attends to scientific evidence, accepted guidelines, and available resources. This approach should focus on quality, safety, appropriateness, and utilization. This article reviews and discusses the consideration of imaging adult patients with headache.

Neuroimaging utilization and findings in headache outpatients: Significance of red and yellow flags

Background

Neuroimaging for headache commonly exceeds published guideline recommendations and may be overutilized.

Methods

We conducted a retrospective cross-sectional study of all outpatient community patients at Mayo Clinic Rochester who underwent a neuroimaging study for a headache indication in 2015. We assessed the neuroimaging utilization pattern, clinical application of red flags, and concordance with neuroimaging guidelines.

Results

We identified 190 outpatients who underwent 304 neuroimaging studies for headache. The median age was 46.5 years (range 18–91 years), 65% were female, and most reported no prior history of headache (n = 97, 51%). A minority of patients had prior brain imaging studies (n = 44, 23%) and neurological consultations for headache (n = 29, 15%). Few studies were ordered after consultation with a neurologist (n = 14, 7%). Seventy-seven percent of patients were documented to have a “red flag” justifying the imaging study. Abnormal neuroimaging findings were found in 3.1% of patients with warning flags (5/161); carotid dissection (n = 3) and reversible cerebral vasoconstrictive syndrome (n = 2). An estimated 35% of patients were imaged against guidelines.

Conclusions

The prevalence of serious causes of headache in a community practice was low despite the presence of a documented red flag symptom. Inadequate understanding or application of red flags may be contributing to recommendations to image patients against current guidelines. Interventions to reduce unnecessary neuroimaging of patients with headache need to be designed and implemented.