Headache, Migraine, and tension headache
Headache is a multi-composite disorder characterized by episodic or recurrent acute pain in the region of the head. Among the general population, headaches are highly prevalent and receive growing attention not only because they affect people’s quality of life, but also because they can have a significant economic impact . Headache causes high global socioeconomic costs, and the currently available treatment options are inadequate . One in 40 people with migraine and one in ten with probable Medication overuse headache(MOH)have caused their partners to lose work-time in the last 3 months .
TYPES OF HEADACHE
The IHS classifies headache as primary, secondary, or of other types. Idiopathic or primary headache syndromes are disorders in which there is a temporary or permanent dysfunction of the central nervous system, often genetically determined, without apparent organic lesion. They include migraine, tension headache, and the trigeminal autonomic cephalalgias among which “cluster headache” . A recent European study reports a gender-adjusted 1-year prevalence of 78.6% for any type of headache. Tension-type headache(TTH)and migraine, with an estimated global prevalence of 20.1%and 14.7% respectively, ranked as second and third most common diseases in the world (behind dental caries) in both males and females. Migraine was recognized as the seventh-highest among specific causes of disability globally, responsible for 2.9% of all years lived with disability(YLDs) . Due to its high prevalence, headache has a strong impact on health care programs, policies, and economics. It has also been estimated that 17.7% of males and 28.0% of females lost >10% of days due to migraine and that 44.7% of males and 53.7% of females lost >20% of the days due to MOH . Guidelines recommend treating chronic headaches with antidepressants such as amitriptyline, while in case of sporadic headache episodes (up to 10 days per month), pain can be treated with analgesics or NSAIDs .
osTEOPATHY FOR HEADACHES AND MIGRAINE
The possible effect of Osteopathy could be due to two main mechanisms:
- Increasing the parasympathetic tone
- Inhibiting the release of pre-inflammatory substances .
Headache has been shown to be associated with impairment of both the ANS and the specific autonomic nuclei responsible for pain perception and sustained pain. Patients with a chronic headache may show peripheral and central sensitization, and lack of habituation.
Habituation is defined as “a response decrement as a result of repeated stimulation”  and is a common feature of responses to any kind of sensory stimulation. It is a ubiquitous phenomenon observed in different experimental settings and in neuronal circuits of a wide range of complexity, from the withdrawal reflex of the gill and siphon in Aplysia to the autonomic and behavioral component of the whole-of-body reflex called the “orienting response” in humans .
Dual-process theory in headaches
In the ‘70s, Groves and Thompson proposed the “dual-process theory”, stating that two separate and opposing processes, 1.depression (habituation) and 2.facilitation (sensitization), compete to determine the final behavioral outcome after a sequence of repetitive stimuli . According to the dual-process theory, sensitization is the side of the pendulum that, when present, prevails at the beginning of the stimulus session and accounts for the initial transitory increase in response amplitude, whereas habituation occurs later during the course of the recording session and accounts for the delayed response decrement .
headaches at the synaptic level?
At the synaptic level, the stimulus-response pathway interacts with an external “state” system represented by various “tonic” non-specific and motivational circuits, including the ascending reticular activating system and related structures. In humans, these structures comprise the monoaminergic nuclei in the brainstem, that are critically involved in the central processing of arousal, control of the signal-to-noise ratio generated by sensory stimuli at cortical and thalamic levels, and endogenous anti-nociception .
The headaches that accompany certain intracranial pathologies (such as meningitis, subarachnoid hemorrhage, and tumor) have been considered to result from mechanical or chemical stimulation of pain-sensitive structures of the intracranial meninges. Although the recurrent headache of migraine is of unknown origin and is not accompanied by an identifiable pathology, it shares with intracranial headaches features that suggest an exaggerated intracranial mechano-sensitivity (worsening of the pain by coughing, breath-holding or sudden head movement). One possible basis for such symptoms would be the sensitization of meningeal afferents to mechanical stimuli .The second phenomena belonging to the so-called pain-matrix.
In migraine, the majority of electrophysiological studies between attacks have shown that, for a number of different sensory modalities, the brain is characterized by a lack of habituation of evoked responses to repeated stimuli. This abnormal processing of the incoming information reaches its maximum a few days before the beginning of an attack, and normalizes during the attack, at a time when sensitization may also manifest itself.
In tension-type headache (TTH), only a few signs of deficient habituation were observed only in subgroups of patients. By contrast, using grand-average responses indirect evidence for sensitization has been found in chronic TTH with increased nociceptive specific reflexes and evoked potentials. Generalized increased sensitivity to pain (lower thresholds and increased pain rating) and dysfunction in supra-spinal descending pain control systems may contribute to the development and/or maintenance of central sensitization in chronic TTH. Cluster headache patients are characterized during the bout and on the headache side by a pronounced lack of habituation of the brainstem blink reflex and a general sensitization of pain processing. A better insight into the nature of these ictal/inter-ictal electrophysiological dysfunctions in primary headaches paves the way for novel therapeutic targets and may allow a better understanding of the mode of action of available therapies.
Underlying dysautonomic symptoms are reported to reduce the release of norepinephrine and to increase the secretion of dopamine and prostaglandins.Neurophysiological data suggest that lack of habituation during stimulus repetition despite an initial normal or slightly lower response amplitude is a functional, probably genetically determined, property of the brain in migraineurs between attacks . Abnormalities of the habituation/sensitization mechanisms were discovered in migraine.
In episodic migraine, most published EP studies show two characteristic changes: a lack of habituation on recordings performed between attacks and sensitization during the attack, especially with somatosensory stimuli. The habituation deficit normalizes during attacks, whereas sensitizations vanishes between attacks, but in the immediate pre-ictal phase both sensitization and deficient habituation may variably co-exist in response to non-noxious and pain stimuli. In patients who developed MOH the cortical response pattern could be locked in a pre-ictal state associating both initial sensitization and late deficient habituation, which contrasts with episodic migraine where these cortical states alternate. Recent works suggest that an abnormal rhythmic activity between thalamus and cortex, namely thalamocortical dysrhythmia, may be the pathophysiological mechanism subtending abnormal information processing in migraine.
osteopathy for headache and migraine
Craniosacral Osteopathy in the cranial field was pioneered by a student of A.T. Still’s named William Sutherland, DO, (1873–1954)and remains one of the more controversial areas of osteopathic manipulative medicine. Central to the cranial technique is the concept of the “primary respiratory mechanism“, which consists of the inherent rhythmic motion of the brain and spinal cord, fluctuation of cerebrospinal fluid (CSF), mobility of intracranial and intraspinal membranes, the articular mobility of cranial bones, and the involuntary mobility of the sacrum between ilia. The goals of various treatment modalities are to normalize nerve function, eliminate circulatory stasis, normalize CSF fluctuation, release membranous tension, correct cranial articular strains, and modify gross structural patterns. It is important to note that many treatment modalities across the spectrum of OMT are applied to the cranium in addition to those affecting the primary respiratory mechanism. The cranial techniques require special training and should be performed only by a certified manual osteopath in craniosacral therapy. Cranial manipulation is contraindicated for patients with recent trauma, a lack of biomechanical dysfunction or an aversion to receiving treatment.
results of osteopathy for headache and migraine
According to Anderson, Rosemary & Seniscal , twenty-nine patients with TTH according to the International Headache Classification Subcommittee, 2004, were recruited for this study and randomly placed in either a control or experimental group. Both groups practiced PMR exercises at home while the experimental group also received 3 osteopathic treatments. All participants recorded headache frequency and intensity in a headache diary (HD) for 2 weeks pretreatment, and continued recording during the treatment period until reassessment for a total of 6 to 7 weeks. Results indicated that the number of Headache Free Days Per Week was significantly improved (P= .016) in the experimental group. Two other measures, the Headache Degree of Improvement (P= .075) and the HD rating (P= .059), which combine headache frequency and intensity, did not meet their criteria for statistical significance but both scores are <.10 indicating a trend toward improvement in the experimental group that is clinically significant. The HD Rating also showed that the experimental group improved 57.5%, while the control group improved by 15.6%. The intensity of the headache did not show a significant improvement (P= .264). The people in this study who did relaxation exercises and received 3 osteopathy treatments had significantly more days per week without headache than those who did only relaxation exercises which was a good outcome.
Then,according to another study  which 105 subjects were included,At the end of the study, ANOVA showed that OMT significantly reduced HIT-6 score (mean change scores OMT-conventional care: -8.74; 95% confidence interval (CI) -12.96 to -4.52; p<0.001 and OMT-sham: -6.62; 95% CI -10.85 to -2.41; p<0.001), drug consumption (OMT-sham: RR=0.22, 95% CI 0.11-0.40; OMT-control: RR=0.20, 95% CI 0.10-0.36), days of migraine (OMT-conventional care: M=-21.06; 95% CI -23.19 to -18.92; p<0.001 and OMT-sham: -17.43; 95% CI -19.57 to -15.29; p<0.001), pain intensity (OMT-sham: RR=0.42, 95% CI 0.24-0.69; OMT-control: RR=0.31, 95% CI 0.19-0.49) and functional disability (p<0.001). These findings suggest that OMT may be considered a valid procedure for the management of migraineurs. In another meta-analysis, researchers observed that spinal manipulation reduced migraine days with an overall small effect size (Hedges’ g=-0.35, 95% CI: -0.53, -0.16, P<.001) as well as migraine pain/intensity. Then, they concluded that Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. In a systematic review of randomized clinical trials (RCTs) on manual therapies for migraine performed by Chaibi A et al, The RCTs suggested that massage therapy, Osteopathy, physiotherapy, relaxation, and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
In another Meta-Analysis , researchers identified a total of 10 RCTs, 7 of which were included in the meta-analysis. For the HIT-6 scale, meta-analysis showed statistically significant differences in favor to manual omt therapy both after treatment (mean difference (MD) – 3.67; 95% CI from – 5.71 to – 1.63) and at follow-up (MD – 2.47; 95% CI from – 3.27 to – 1.68). FortheHDI scale, the meta-analysis showed statistically significant differences in favor to manual therapy both after treatment (MD – 4.01; 95% CI from – 5.82 to – 2.20) and at follow-up (MD – 5.62; 95% CI from – 10.69 to – 0.54). Other scales provided inconclusive results.
Finally, they concluded that Manual therapy should be considered as an effective approach in improving the quality of life in patients with TTH and MH, while in patients with CGH, the results were inconsistent.
conclusion on osteopathy for headache and migraine
Overall, it is believed that cranial osteopathy can be effective in headaches including migraine and it can mitigate both the severity and frequency of attacks.
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