Pinpointing Pain
Monday August 18, 2008
Print This- Select Text Size:
advertisement
At least, that’s the way it seems to Carolyn Libert, MSPT, who practices in the Washington D.C. area. The person she usually sees with this type of headache — pain that originates from muscle tension or myofascial structures — has a fairly specific profile, and it is a young one. Typically, it occurs in a high-achieving adolescent. “They are girls who put a lot of pressure on themselves,” she says.
The clinical signs of this kind of headache are steady, persistent head pain without nausea, or, as one teenager describes it, like a “seeping egg yolk” that spreads until it hurts all over the inside of the patient’s head. Often, medication fails to significantly mitigate either the duration or frequency of symptoms.
Healthcare clinics and other outpatient settings have reported findings that may expose a possible underlying reason for a surge in younger female patients. With an earlier age of menarche (10 or younger), something public health officials term “allostatic load” may be a factor.
Allostatic load is the cumulative wear and tear that occurs in the tissues and organs of an individual under chronic stress, usually related to neuroendocrine hormone release. In a study using a government database, investigators from Brown University found that there seems to be a relationship between high allostatic load and young women who have an early onset of menstruation.
Teens and young adults under the pressure of high expectations seem to be at particular risk. Additionally, there may be a hidden etiology for girls, as the number playing sports and the increasing level of competitiveness has swelled during the past few decades.
Two other trends may be contributing to cervicogenic headache among these young athletes: the generally increased risk of dehydration, and the heightened quest for weight control. Compared with their adult counterparts, children have lower sweating capacity, a greater body surface area-to-weight ratio, and lesser thirst response, diminishing their ability to reduce heat and remain adequately hydrated. Compounding the risk of dehydration, many also use food restriction, diuretics, and even vomiting to help control their weight when participating in weight-sensitive sports such as wrestling, swimming, long-distance running, and gymnastics.
In one study, when neurologists examined factors that may explain treatment failure, they discovered that an incomplete or incorrect diagnosis, inadequate identification of exacerbating factors, overlapping comorbid conditions, a patient’s unrealistic expectations of treatment, and inadequate intervention (both pharmacologic and nonpharmacologic), are all contributors.
But among experts, there is a consensus that correctly identified craniovertebral dysfunction is often the cause of cervicogenic, benign headache, says Paul Roubal, PhD, PT, FAAPM, director of Physical Therapy Specialists in Troy, Mich.
Many times, headache pain can be mitigated or alleviated by muscle-strengthening approaches for the neck, he explains. The protocols may differ but the goals are the same: strengthening of deep neck flexors and rotators, and improvement of gross neck extension strength. “The first order of any headache is to look at the neck,” Roubal says.
Some experts maintain that poor posture can be responsible for a large portion of cervicogenic headaches. However, many people with poor posture don’t report this type of headache, and patients with this form of headache may not show any sign of postural disturbance. In one small study of 20 women, Roubal and colleagues found that although postural problems were unrelated to their cervicogenic headaches, neck weakness was. The patients studied generally had only about one-third of the cervical muscle strength as their counterparts who didn’t suffer from headaches.
More Info
Resources
- • Allsworth, J. E., S. Weitzen, and L. A. Boardman. 2005. Early age at menarche and allostatic load: data from the third national health and nutrition examination survey. Ann Epidemiol 15:438-44.
• Lipton, R. B., S. D. Silberstein, J. R. Saper, M. E. Bigal, and P. J. Goadsby. 2003. Why headache treatment fails. Neurology 60:1064-1070.
• Placzek, J. D., B. T. Pagett, P. J. Roubal, B. A. Jones, H. G. McMichael, E. A. Rozanski, and K. L. Gianotto. 1999. The influence of the cervical spine on chronic headache in women. Journal of Manual and Manipulative Therapy 7(1): 33-39
• Vinson, D. R., T. R. Hurtado, J. T. Vandenberg, and L. Banwart. 2003. Variations among emergency departments in the treatment of benign headache. Ann Emerg Med 41:90-97.
Libert believes it is important to address treatment in a multidisciplinary way, including psychological intervention and medical management. At her clinic, a neurologist is often the referring physician, and the adolescent is advised to speak with a psychologist or psychiatrist when appropriate.
One of the benefits of psychological intervention is that, sometimes, these teenagers seem to have secondary gains from their headache-related disability, such as parental attention or school absences. “Some don’t want to let their pain go,” Libert observes.
Because adolescence is a time of profound physical and biomechanical alteration with ligament growth, hormonal shifts, and other musculoskeletal changes, pain can be consistent with the progression to adulthood, suggests Kurt Klein, PT, MTC, who practices in Fort Lauderdale, Fla. Causes of headache in this transitional period can be related to the all-too-frequent habit of slumping. “You do see patients with chronically poor posture at risk for this,” he says.
On examination, adolescents often have a history of poor posture and body awareness, slumping when they walk or stand. So the first approach may be to correct that problem, with postural retraining and lumbar strengthening, Libert contends. Also, the specific triggers for headache — such as nervousness over tests, for example — need to be identified. When they are, exercises, including biofeedback techniques, can be employed by these adolescents to help diminish or avoid the onset of headache, she says.
The one-on-one aspect of physical therapy, as well as the actual therapeutic regimen, seems to help these young patients, according to Libert. “We talk to them,” she explains. “Trust develops, and sometimes we [act] more like a counselor [than a therapist].” Treatment plus trust often leads to a happy ending, which can be gratifying to patient and therapist alike.
Anne Scheck is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to pteditor@gannetthg.com.
