• Yoon Clinic

About diagnosis and treatment of Tension-type Headache and Migraine Headache


Introduction

Globally, it has been estimated that prevalence among adults of current headache disorder (symptomatic at least once within the last year) is about 50%. Half to three quarters of adults aged 18–65 years in the world have had headache in the last year and, among those individuals, 30% or more have reported migraine. Headache on 15 or more days every month affects 1.7–4% of the world’s adult population.

The main classes of drugs to treat headache disorders include: analgesics, anti-emetics, specific anti-migraine medications, and prophylactic medications. However, most of the time, medication allows just temporally pain relief and not only that, medication itself may induces rebound headaches (medication-overuse headaches).

Primary headache disorders – migraine, tension headache and cluster headache – constitute nearly 98% of all headaches; however, secondary headaches are important to recognise as they are serious and may be life threatening.

“Red flags” for secondary disorders include sudden onset of headache, onset of headache after 50 years of age, increased frequency or severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema and headache subsequent to head trauma. A thorough neurologic examination should be performed, with abnormal findings warranting neuroimaging to rule out intracranial pathology. However, the yield of significant abnormalities on neuroimaging in patients with chronic headaches is 1% to 3%.

Symptoms

Tension-type (TTH)

  • Dull, aching head pain

  • Sensation of tightness or pressure across your forehead or on the sides and back of your head

  • Tenderness on your scalp, neck and shoulder muscles

Migraine

  • Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours.

  • Symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell.

Mechanism of development

  1. Tension pain in the head and scalp caused by trapezius muscle and semispinalis capitis muscle tension that are entrapping greater-lesser occipital nerve and 3rd occipital nerve.

  2. Ischemic pain in the head and scalp due to trigger point (TrP) in upper portion splenius capitis muscle which is oppressing occipital artery

  3. Pain and swelling of the occipital area due to TrP in upper portion splenius capitis muscle which is oppressing occipital vein

  4. Frontal and orbital pain due to tension in the frontalis muscle from muscle fiber excitation in the occipitalis muscle caused by TrP induced entrapment of occipital branch in the posterior auricular nerve.

  5. Temporal area pain caused by entrapment of zygomaticotemporal nerve due to temporal muscle tension.

  6. Initial cause of the TTH is due to TrP in the nape muscle and secondary causes are; physical fatigue, emotional stress, alcohol, menstrual cycle, atmospheric pressure and viral infection etc.


Diagnosis

In case of chronic headache, it is safe to get MRI to confirm that patient has no cerebral pathology. Find the trigger point build up in (GB21) trapezius, (GB20) semispinalis capitis muscle and (GB12) splenius capitis muscle that are oppressing occipital nerve, vein and artery. When patient has temporal pain, find the trigger point build-up in the (Tai Yang EX3) anterior portion of temporal muscle.

GB21 is a center of the upper trapezius muscle and when there is a TrP which is entrapping greater occipital nerve, it will induce pain in the innervation area of the nerve.

GB20 is area where upper part of semispinalis capitis muscle attaches to occipital nuchal line and when this area has a TrP, it will create occipital pain due to entrapment of greater occipital nerve that is coming through semispinalis capitis and trapezius muscle.

GB12 is where slightly below the splenius capitis muscle attaches to mastoid process. When this has TrP, it can either induce ischemic or congestion pain due to oppression of occipital artery or vein. Sometimes, posterior auricular occipital branch of the facial nerve can be entrapped.

Tai Yang (EX3) is a depression about 2cm posterior to the midpoint between the lateral end of the eyebrow and the outer canthus of the eye. This area TrP can oppress the zygomaticotemporal nerve and create pain in the temporal region.

Treatment

Acupuncture

GB21, GB20, GB12 and constitutional acupuncture points [emotional stress (LV2 or LV3)/ Physical fatigue (ST36)]

Fascial Decompression Cupping

Moving fire cupping is especially effective for TTH from atmospheric pressure changes due to cold and wet.

Trigger point Injection #1

Injecting 2cc of lidocaine 1% on each trigger point

Trigger point Injection #2

Injecting 0.2 ~ 0.5cc of Trigger-Point Injection (TPI) solution (D5W 4cc + lidocaine 1% 1cc) on each time when there is a fasciculation in the muscle with TrP

Prolotherapy

Injecting 0.2 ~ 0.5cc of the prolotherapy solution (Dextrose 13% ~16 % 3cc + 1% lidocaine 2cc) on each pathological entheses

Herbal Medicine

Majority of TTH in the practice is fall in to Tai Yang Bing Patterns. Ge Gen Tang is one of the most common formula can be used in TTH

References

  1. Headache disorders. (n.d.). Retrieved March 03, 2018, from http://www.who.int/mediacentre/factsheets/fs277/en/

  2. Ahmed, F. (2012). Headache disorders: differentiating and managing the common subtypes. British Journal of Pain,6(3), 124-132. doi:10.1177/2049463712459691

  3. Evaluation of acute headaches in adults. (2001). Journal of Osteopathic Medicine,4(1), 31-32. doi:10.1016/s1443-8461(01)80045-9

  4. Callaghan, B. C., Kerber, K. A., Pace, R. J., Skolarus, L. E., & Burke, J. F. (2014). Headaches and Neuroimaging. JAMA Internal Medicine,174(5), 819. doi:10.1001/jamainternmed.2014.17

  5. Aminoff, Roger P. Simon, David A. Greenberg, Michael J. (2009). Clinical neurology (7 ed.). New York, N.Y: Lange Medical Books/McGraw-Hill. pp. 85–88. ISBN 9780071664332.

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