When headache is a pain in the neck

Physiotherapy is increasingly recognised as a treatment for headaches. Louise Hunt explores this emerging field

Man with headacheFor 16 years Sonja Lord suffered from headaches and migraines, which made it hard for her to focus on everyday tasks. Just running after her children could bring on a headache. The only advice she was given from countless visits to her GP was to avoid potential triggers, such as cheese, chocolate and red wine. ‘I was really stuck in a rut. I couldn’t do anything without inducing a headache,’ says Ms Lord, who also suffered from a stiff neck and describes having a ‘fuzzy head’ most of the time. That was until she was invited to take part in the UK’s first study to identify whether one particular physiotherapy technique could help to manage migraines (see panel: Building the evidence base). Having completed a patient diary and screening to rule out other possible causes of headache, Ms Lord was offered a series of six physiotherapy treatments. She says: ‘I felt a difference from the first treatment. I’m on my fifth now and with each one my headaches have been getting better... I still get the odd one, but now I can run and play with the kids.’ She is aware of other effects too. ‘I feel like I’ve had a spring clean in my head. Colours are really vibrant, and when I went shopping the other day I noticed that I wasn’t getting confused,’ she says.

Dramatic results

For patients like Ms Lord, physiotherapy can produce dramatic results where years of medication and dietary advice have failed. Traditionally, medics thought headaches and migraines were caused by abnormalities in the blood vessels in the brain, but most neurologists are now beginning to accept that some headaches can be caused by dysfunction in the upper cervical spine. Cervicogenic headaches, as they are known, are classified by the International Headache Society as one of over 300 types of headache. While mechanical dysfunction is recognised as being a factor in headaches and migraines, there is a lack of awareness among the medical profession and the general public of how physiotherapy can ease the conditions. The challenge now is for physiotherapists to show how they can help. Alison Sentance is involved in raising the profile of physiotherapy in the treatment of headaches. She is, as far as she is aware, the only extended scope practitioner physiotherapist specialising in headaches. Based at St George’s healthcare trust, London, she says: ‘I believe I have a unique role in being a physiotherapist working in a neurology headache clinic.’ As a primary practitioner, she diagnoses headache and directs treatment management, effectively playing the same part as a neurologist by performing neurological examination techniques, such as fundoscopy, which are beyond routine physiotherapy training, to rule out serious pathology. (Fundoscopy is examination of the eye to look for signs of pressure in the brain, which could indicate serious pathology such as a brain tumour.) As well as screening and referring patients for physiotherapy, she also receives referrals from neurologists and GPs. ‘By the time patients get to me I can safely assume the problem is at least partially due to dysfunction in musculoskeletal tissues of the upper cervical spine,’ she says.

a range of techniques

Ms Sentance treats patients with cervicogenic headache and migraine using a range of techniques to restore movement and maintain neutral posture in the upper spine. One technique was developed by Australian physiotherapist Dean Watson, and is the focus of the UK clinical trial in which Ms Lord is taking part. However, Ms Sentance is keen to stress that this approach is ‘one, rather than the be all and end all’, and is wary that some physios may become too indoctrinated in one method. Another assessment technique that can be useful, she says, is the cervical flexion-rotation test where patients’ heads are bent and turned to identify stiffness and pain in the cervical vertebrae. While Ms Sentance is in the unusual position of receiving referrals directly from neurologists in her department, she says there is a general lack of awareness among the medical profession of the role physiotherapists can play in treating headaches. ‘Neurologists don’t necessarily think of physiotherapy for treating cervicogenic headaches. They would treat with medication and the headache may not go away.’ She suggests this may be because neurologists are more familiar with physiotherapists treating patients with neurological conditions, such as stroke or multiple sclerosis. ‘They don’t realise headache can be a musculoskeletal disorder as well as a neurological one, so it is a question of raising awareness of what physiotherapists can do.’ Physiotherapist Jayne Davies finds it frustrating that physiotherapy for headaches does not get the publicity it deserves. Ms Davies works in both the NHS and privately, and has trained in a variety of techniques for treating headaches. She says a breakthrough only occurred in her work after taking Dean Watson’s course, and she is now an assistant teacher on the UK courses. ‘It’s quite amazing. I’ve had a lot of patients who have had migraines for years and they have gone completely after using Dean Watson’s treatment, although this doesn’t happen for everyone.’

Watson’s technique

Mr Watson’s approach is based on examining the upper cervical spinal segments for dysfunction, using slow, sustained, passive movement and positioning. His theory proposes that if there is mechanical dysfunction, then manipulation will first reproduce the familiar head pain and its associated features, but that this pain will then lessen as the technique is sustained. It is the reproduction of a headache, through manipulation by a physiotherapist, that is considered to be a key diagnostic of cervicogenic headache. Ms Davies stresses the treatment is only suitable for patients with chronic benign headaches, which they have had for at least three months, as opposed to acute headaches that could be caused by serious conditions such as brain tumour or haemorrhage. ‘We ask lots of screening questions and this is why the technique has to be done by trained hands.’ She also notes that the therapy, which initially involves bringing on a headache, ‘can be quite scary for the patient’. However, as she explains: ‘If the headache isn’t brought on by pressing on the joints, there would be no point in proceeding as it would indicate that it’s not a cervicogenic problem.’ The benefit of this is that within the first assessment it is clear whether or not physiotherapy can help. Michael O’ Reilly works in private practice and has been treating headaches for six years. He uses a variety of approaches. ‘My treatment is based heavily, but not exclusively, on Dean Watson’s technique, which is a very thorough assessment of the upper cervical spine, integrated with other neck courses, such as spinal segmentation stabilisation techniques. ‘Once you have identified the source of the headache there are a number of different modalities you can use and not everyone will respond in the same way, so it’s difficult to be prescriptive. You need a range of skills and experience to treat headaches effectively,’ he says. His view is that although it is important to identify the specific neck joints in cervicogenic headache, the source of the dysfunction is often in the middle of the spine. ‘Commonly, it is a problem with the mobility of the thoracic spine from hunching over desks that can cause headaches. ‘So the treatment approach has to address these causes too. You need good clinical reasoning and palpatory skills, but you also need to be able to integrate the approaches into the bigger picture of what is causing the headaches. I would say most non-traumatic headaches are caused by lifestyle factors. This is something that can be effectively dealt with by physiotherapy.’

Raising awareness

Ms Davies is a passionate advocate of physiotherapy’s role in this field. ‘Headache physiotherapy is developing as a specialty,’ she says. However, she recognises the need to raise awareness of how physios can help in the treatment of headaches and migraine of cervicogenic origin. ‘We have physios out there who have been trained and are raring to go, but patients are trickling through. We don’t have the evidence base at the moment to get the public attention. I think if more patients knew about physiotherapy treatment for headaches they would ask for referrals.’ To help those working in this field to raise the profile of headache physiotherapy and to support each other, Ms Davies set up the headache clinical interest group – a non-official body with approximately 100 members, who participate in discussions through the group’s network on the Society’s member networking website, interactiveCSP. Looking to the future, the ambition over the next five years is for greater recognition of what physiotherapy can achieve in headache and migraine management, and a solid evidence base from which to work. ‘Hopefully, there will be more robust evidence on the efficacy of treatment techniques to the neck for headache like deep neck flexor strengthening and mobilisation of the upper cervical spine too,’ says Ms Sentance. ‘I’ll consider myself successful if the role of physiotherapy in management of benign recurring headache is more formally recognised and neurologists are happier to refer headache for manual therapy.’ And she adds: ‘It would be nice if I had some peers.’ FL FURTHER INFO To contact the headache special interest group, email jayne.davies@buryphysio.co.uk Jull G et al. ‘Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches’, Cephalalgia (2007), 27(7):793

Building the evidence base

Physiotherapist Ian Davidson at Manchester University is leading the clinical trial testing the effectiveness of fellow physio Dean Watson’s technique for migraine sufferers. The study, which began recruiting in April 2007, is being carried out in three private physiotherapy practices in the northwest (two in Lancashire and one in Cheshire). The study was awarded £95,000 by Physio First through its charitable trust, the Private Physiotherapy Educational Foundation. Patients have been recruited through the Migraine Action Association, local universities and GPs. Mr Davidson says around 90 are needed to complete the trial and 76 have been recruited so far, adding that a high attrition rate has made progress difficult. ‘We are about a year and a half away from completing,’ he says. Patients are screened and asked to complete a diary before being referred for six physiotherapy sessions based on Mr Watson’s technique. ‘I hope the study does help towards developing an evidence base for headache physiotherapy,’ says Mr Davidson, adding: ‘I would hope from this trial I would be able to put in a proposal for a larger national trial.’ For details of Dean Watson’s technique see www.headacheandmigraine.com
Louise Hunt

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