When Headache is Ominous

A CEU Course from Massage Therapy Practice.com

This article does not attempt to teach you how to diagnose headache syndromes.

Diagnosis is the province of the physician.

However, by becoming more aware of primary and secondary headaches, a massage therapist can be more alert to when their client may be in danger.

Never hesitate to refer your client back to their physician or emergency room if you have any concerns!

 Introduction

Neck pain and headaches are meat and potatoes - or rice and tofu - to most massage practices. Myofascial tension and trigger points in the neck, scalp, face and/or jaw contribute to many of our clients' headaches. However, there are times when a headache is secondary to a serious condition that requires medical attention and management.

This article overviews these types of presentations, so that the massage therapist can refer clients to their physician if there is a significant red flag.

Primary and Secondary Headaches

Headaches are classified as primary or secondary. While they can be painful or even disabling, primary headaches are benign conditions in which the headache itself is the primary condition. The most common primary headaches are tension-type, migraine and cluster headaches. Secondary headaches are headaches that are secondary to some other process such as a blood vessel bleeding in the head, infection, tumor, analgesic overuse, etc...

Let’s explore the three common types of primary headaches and then move on to some of the common, and dangerous, secondary headaches.

Tension-Type Headache

Tension-type headache is the commonest source of head pain. Roughly 40% of the population will suffer from one or more episodes during the course of a year (Loder).

Pain is often described as a dull ache that starts at the base of the skull or in the forehead that may then spread to other parts of the head and face as it builds in intensity and may express itself as pressure and throbbing. An episode can last from hours to days (Issacs).

Tension-type headache may occur in the absence of any excessive muscle tension or psychological stress (Cady). Myofascial trigger points can exist in muscles with no increased electrostatic tone (alpha moto neuron activity (Simmons). A related diagnosis preferred by physiotherapists and chiropractors is cervicogenic headache, where muscle and/or joint factors in the neck cause or contribute to headache (Jull).

Massage therapists ought to familiarize themselves with the common myofascial trigger points that refer pain to the neck and head (Travell). For example, when a client reports headaches focused on the top or vertex of the head, we need to palpate the splenius capitis for trigger points (Travell).

Tension-type and cervicogenic headaches are often correlated with head forward posture that loads the neck muscles with tension, apical breathing (breathing with the neck and shoulder girdle muscles) and stressful cycles of thoughts and feelings. Facet joints in the upper part of the neck also frequently contribute to headache and respond well to manual therapy (Jull).

Massage therapy and self care can often help with these problems (Quinn, and my clinical experience). It should be noted that a recent Cochrane review found little support for massage therapy's effectiveness in relieving mechanical neck pain, however they also determined that there were few solid research studies to base a decision on (Haraldsson).

Migraine Headache

Migraine is the second most common primary headache condition. Roughly 18% of women and 6% of men will suffer an episode of migraine over the course of a year (Loder).

Migraine are severe headaches that is can be either single sided or bilateral. Some migraines are preceded by a transient neurological disturbance termed an aura. Auras include visual symptoms such as blind spots, flashing light; tingling or numbness in one or more body regions; and even speech problems and/or weakness.

While there are many types of migraine, the two most common are those without aura (common migraine) and those with an aura (classic migraine). Only about a quarter of migraine sufferers experience an aura, and they may not have an aura with every migraine (Taylor).

Migraines are most commonly characterized by:

• Severe, usually unilateral headache
• Pain is usually localized in the temple, but could be anywhere
• Pounding, throbbing or pulsing pain
• Nausea and/or vomiting
• Aversion to bright lights (photophobia), loud sounds (phonophobia), and/or strong smells
• Pain that worsens with movement

Migraines can be difficult to treat medically (Taylor). In my massage experience (> 20 years of practice) it is also difficult to resolve migraines with massage therapy, although I have had some success with allieviating the frequent tension headaches that often plague the client between migraine attacks.

Cluster Headache

Cluster headaches are intense, piercing one-sided attacks of pain with 92% of people experiencing pain behind the eye and 70% have pain in the temple (Adams). It is common to also experience pain in the upper teeth, jaw, forehead and cheek (Adams). Attacks are clustered at the same time of the day or night. Each episode can last from a ¼ of an hour to an hour and a half. They can even occur at night, awakening the client from sleep (Adams).

There is also autonomic dysfunction, which is more severe on the same side as the head pain. Tearing of the eye, flowing of mucous out of the nose, or blocked nasal passage, reddening of the eye and swelling or blanching of the forehead or cheek are common (Adams).

A key feature of cluster headaches is restlessness. People suffering from cluster headaches often pace restlessly (in contrast to migraine sufferers who usually prefer to not move at all)(Adams). There are medical treatments that are often very helpful, but a small subset of sufferers will not be able to find a successful treatment. It is unlikely that massage therapy will be of much benefit in aborting cluster headaches, although it may be useful in dismantling residual tension after or between clusters of attacks.

Secondary Headaches are Usually "New" Types of Headaches

If your client has had a similar headache in the past, they likely have a primary headache syndrome, either tension-type or migraine (Loder).

It is when the headache is either of a type the client has never experienced before, or is the "worst" headache they have ever felt that one needs to ask more questions.

Some red flags that suggest medical problems include:

• First, worst or different type of headache than they have ever experienced
• Sudden onset and peak intensity within seconds (“thunderclap” headache), or “worst headache ever”.
• Abnormal neurological signs or symptoms such as altered ability to think or personality change, visual disturbance, numbness, loss of coordination or strength, loss or alteration in sense of smell, taste, or hearing.
• Headaches that begin after lying down, especially if they awaken the client from sleep
• Headaches that begin with, or remain as, unilateral pulsing pain in synchrony with the heartbeat
• Intense pain that is localized over a sinus or around the teeth
• Fever and/or generalized and severe neck stiffness
• Recent onset in client with cancer, HIV, anticoagulation therapy, or > 50 years of age
• Onset during pregnancy

( List from Loder and Issacs)

Let's look at some common secondary headaches, beginning with the most acute presentations.

Thunderclap or Sentinel Headache

Exceedingly abrupt onset headache, or "thunderclap" headache, is a hallmark of subarachnoid hemorrhage (SAH) (deFalco, Loder). The pain usually subsides in one or two days, but can continue for two weeks or until a major hemorrhage. Thunderclap headaches are also called sentinel headaches (SH).

Not all people with thunderclap headaches have a blood vessel bleeding in their head. Only a tenth or a ¼ of people who present at an emergency department with the most intense headache of their lives will actually have a SAH (de Falco). And only about 1 in 5 people with a SAH will report a headache.

If your client reports a transient loss of consciousness at the onset of the sentinel headaches then it is more likely that they may have a SAH (deFalco). The pain may not be strong, or long in duration; it is the abrupt onset and the feeling that this headache is so unlike anything they have ever experienced before that is the red flag.

Treatment of SAH is through medication and/or surgery. Any client who reports a sentinel or thunderclap headache should be sent to their physician or emergency department (deFalco).

Fever, Stiff Neck, Poor Circulation, Neurological Dysfunction

If a headache is associated with fever, then the client may be suffering from an intracranial infection such as meningitis, encephalitis or a brain abscess (Loder).

Meningitis is more common in children and adolescents and can be fatal. The classic signs of meningitis include fever, stiff neck and a rash (Thompson). However, early signs are clustered around sepsis that lessens peripheral circulation. Cold hands and feet and abnormal skin color are often the earliest signs of meningitis (Thompson). If symptoms escalate over the course of hours then a trip to the emergency department is necessary.

Encephalitis is often characterized by fever and neurological changes in personality, seizures, hemiparesis (paralysis of a side of the body), and papilledema (swelling of the optic disc) (Loder). The sheath of the optic nerve is continuous with the subarachnoid space in the brain, so swelling in the subarachnoid space can flow through the sheath of the optic nerve and into the back of the eye (Wikipedia).

Brain absecess are most commonly indicated by a dull, aching headache that varies according to where the abscess is located (Loder).

Any client with headache that is associated with fever, lack of peripheral circulation, generalized neck stiffness that is obviously not mechanical (short muscles and/or restricted joints) and/or neurological dysfunction should be sent immediately for medical diagnosis.

Sub-Acute: Recent Onset, Persistent or Recurrent Headaches

This category includes headaches with onset usually several days to weeks prior the patient seeking medical help. Possible causes include temporal arteritis, brain tumors, adverse (prescription and nonprescription as well as recreational) drug effects, and subdural hematomas. Tension-type and cervicogenic headaches also commonly express themselves in a gradually progressive way.

Brain tumors produce symptoms of neurologic dysfunction far more often and consistently than they produce headache (Franges).

Neurological symptoms and signs include such things as dizziness, lethargy, forgetfulness, gait unsteadiness, diplopia, weakness, cognitive dysfunction or hemiparesis often indicate space occupying lesions in the brain, such as tumors (Franges, Grossman).

Although headaches develop in 2/3 of patients with brain tumors, less than half will be severe; 25% are described as throbbing, and the remainder as dull pain. The majority occur intermittently, while 15% are continuous. The patient is often unable to identify the day on which the pain started (Grossman). However, most of the patients will also have some marked type of neurological signs as well.

When a headache is gradually getting worse over days, weeks or months; is worse at night, awakens the client from sleep and/or worsens with coughing or straining then they should be referred to their physician (Franges).

Medication Overuse Headache (MOH)

Every client with a new headache complaint ought to be asked if they started a new prescription in the preceding few weeks. Many commonly prescribed medications can cause headache as an adverse effect. People with new medications and new headaches need to be referred to their pharmacist or physician.

It is becoming increasingly appreciated that the very medication which people use to combat pain can maintain it. Termed analgesic overuse syndrome, the patient overuses headache medications and creates a syndrome of daily, migraine-like headache (Saper).

Up to 4 % of the population may be suffering from headaches caused by overuse of medication. The medication can be prescription medication (especially narcotics), but can also include over-the-counter (OTC) medications (Kernick).

Medication overuse headache can be a result of an addictive relationship with medications. Especially in clients who have anxiety problems, their attachment to medication can be more about the anxiety diminishing effects of the medication than about pain relief (Saper)

When people who are addicted to their pain medications stop taking them they often experience fear, anxiety, anger and often more pain. The process can be very hard and they require a lot of support, which may include hospitalization (Saper).

It is not just clients who seem to have a daily, addictive, relationship with their medication who can have problems. Analgesic overuse syndrome can also be a product of taking the medication as infrequently as 10 days a month (Kernick)

If your client shows any signs that their medication use may be causing them problems, they need to be referred to their physician and/or pharmacist.

Recent Trauma: Intracranial Hematomas and Neck Injuries

Has your client had a recent fall, head injury or physical trauma?

A subdural hematoma may take up to six weeks for the clot to reach a size that might have clinical relevance, and after that amount of time only about half of people still recall the trauma (Grossman).

People who do recall the injury may say things like, "I'm just not the same. I don't remember things. I can't concentrate anymore." (Grossman)

Subdural hematomas are visualized by magnetic resonance imaging (MRI) or computed tomography (CT). Acute subdural hematoma's require neurosurgery.

It is also important to remember that head or neck injury can lead to fracture of the odontoid process and/or loss of integrity of the alar ligaments stabilizing the odontoid process. This problem requires surgery to stabilize the spine and prevent spinal cord injury and possible death (Issacs).

Over 50 Years of Age: Temporal Arteritis?

Temporal arteritis can occur in people over the age of 50 (and very seldom before the age of 60). The client experiences headache in roughly 80% of cases (Smith).

Women are much more likely to have temporal arteritis than men. Sufferers will commonly avoid putting pressure on their temples (ie. avoid wearing hats).

Temporal arteritis also causes jaw claudication (jaw pain upon chewing). Sometimes this may be the only symptom. Clic k here for a report.

Blindness in one or both eyes is common (about 40%) when temporal arteritis is not treated (Smith).

Medical treatment is with high doses of corticosteroids which prevent complications, especially blindness.

I once treated a male 70-year old client with a left- sided gradually worsening (over weeks) temple headache. I couldn't track down any myofascial factors (especially in his upper trapezius, sternocleidomastoid and temporalis muscles) that caused or aggravated his headache. After the third treatment he mentioned that he was making an appointment with his eye doctor as his vision seemed to be worse lately. At this point I made the possible connection to temporal arteritis and counselled him to see his physician.

Luckily, he did not actually have temporal arteritis, but we played it safe by getting him diagnosed. Unfortunately, I never did manage to help him with his headaches, but we knew they weren't part of a condition that would possible blind him!

Further Red Flags

HIV, AIDS

People living with HIV have a high incidence of central nervous system infection and malignancy. Any complaint of severe headache in this population is immediately suspected of being secondary and requiring immediate medical follow-up, unless they have an obvious migraine or tension headache. Meningitis is common in HIV positive people, too (Grossman)!

Mental Status

Patients with meningitis, encephalitis, and many abnormal cerebral processes often have altered mental status, although this can be very subtle. Prescription and non-prescriptions drug overdose and mismanaged dosing can also affect mental status and be a red flag (Issacs).

Cancer

Metastatic brain tumor ought to be considered whenever there is any history of previous malignancy, especially of the breast, lung, kidney, bowel, prostate, and malignant melanoma as all these cancers can metastasize to the skull (Issacs).

Heart Disease

The pain of angina is often referred outside of the chest and can localize to the jaw and occasionally the forehead (Issacs).

Diabetes

Diabetics are more susceptible to infection, vascular disease, and cranial neuropathies (Issacs).

Constipation

Constipation can cause headache through toxicity and increased intra-abdominal pressure causing pressure on the paraspinal venous plexus which lack valves (Issacs).

Conclusion

Although most headaches seen by massage therapists will be a result of a primary headache mechanism, most likely tension-type or cervicogenic headaches, we must remain vigilant for signs which may indicate serious medical problems at play in our client's condition.

These signs include an atypical pattern or type of headache, unusual or non-response to treatment and the red flags explored in this article.

Subscribers to Massage Therapy Practice.com...

1. Log into the CEU Articles Page of the Member's Section

(click here if you are logged in)  

2. Print the PDF of this article

3. Highlight the most important points.

4. Take the Quiz

5. Take the Quiz again if you need to!

6. Print your Quiz results and Certificate of Completion

7. Put these documents in your Continuing Education Folder

8. Relax!