My ever evolving thought process on headaches Part deux

Sometime last year, I wrote a blog post on how I managed cervical headaches which you can find Here. Having often been at the receiving end of this mostly bad and sometimes extremely painful condition, I have played around with the position I suggested in my last blog post and I have realized that there may be an even better way to manage a painful acute flair up.

Before I proceed to discuss this position, I want to give full credit to my father for this light bulb moment. Here’s how it happened. He was suffering from some dull 2-3/10 pain at his right shoulder for a few years now which of course was intermittent. He would often also complain of tingling and numbness along the median nerve root on his right hand but only around the fingers and palm. So after some assessment I put him on a textbook McKenzie chin retraction and side bending program which did provide him relief but not completely. I noticed that as he wore a turban, the extra weight on the head along with the way it was tied, prevented him from getting into a retracted neck position. Now this, along with sitting at work for 8+ hours for six days a week (ya, that’s right, 6 days, maybe we should stop complaining about our long work weeks, maybe. Lol) was putting him in the dreaded rounded shoulders, blah blah blah … upper crossed posture. So apart from the exercise and manual therapy, I put him in my headache posture in supine hoping for the positive results that I was getting for me and some of my patients.

 

Alas, to my great dismay, this was only minimally helping him. He still complained of shoulder pain and in fact didn’t like to lie in that position for too long (he didn’t want to tell me it wasn’t helping so instead he just asked for a little break. He’s a solid dad). Now, I often saw him place both his hands over/behind his head on numerous occasions and when I inquired about it, he said this was the only position that made him feel better. This got my neurons firing; how could this simple position make him feel better when other advanced physiotherapy techniques had fallen short? This warrantied some investigation and the answer wasn’t too hard to figure out.

 

 

So lets try and break it down- what are some of the conmon postural dysfunctions that we suspect causes headaches, neck pain, shoulder pain and symptoms down the arm?

  1. Forward head and upper cervical extension
  2. Protracted rounded shoulders
  3. Rounded kyphotic upper and middle back region
  4. Downward rotated scapula
  5. Internally rotated shoulders.

On careful observation of  his favorite ‘shoulder pain relieving position’ (For the sake of simplicity, I will use the term-Dad’s position) I realized that this position was putting his body in the exact opposite of some of the above mentioned shoulder dysfunction.

  1. Minimum benefit in correcting forward head position.
  2. Dad’s position forces the shoulders into retraction
  3. Forces some extension at the thoracic spine.
  4. Arm elevation causes scapular upward rotation.
  5. Shoulders comfortably in an externally rotated position.

All of the above seem like thing we recommend to our patients all the time, no wonder his shoulders and arm were happy in this position. However, there were still a few things that had to be tweaked. I asked him to tuck his chin in and to avoid shrugging his shoulders so that the upper traps didn’t tense up. Even better, he reported after trying it a few times!!

Now if you have been following my blog posts from before, you’d know that I almost always consider a shoulder problem as a neck problem and vice-versa. They generally go hand in hand and are my ‘usual suspects’. So given this logic, I applied this on myself and some of my patients for neck related issues , headaches and got some extremely encouraging results. After all what better position to get the neck into retraction then in supine and gently force the thoracic spine into extension with a small pillow under it?? Adding heating packs could be the cherry on top if your a cherry person.

So with the explanation out of the way, I would like to present to you my modified position for cervicogenic headaches (also for neck and shoulder pain).

 

 

 

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My new preferred position for Cervicogenic headaches
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Watch out for excessive cervical extension which may look something like this!
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Tuck that chin in ‘gently’. Do not retract too hard
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Check for elevated shoulders like in the picture. Avoid this.
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Push down the shoulders gently.

 

So after a through assessment, if your patients fit the bill, I recommend you try it out and please let me know your thought on this subject.  As always,

 

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

My ever evolving thought process on Headaches

I have had a long standing history of suffering from headaches. Since I was little, I have had these bouts of headaches at least once a month, where nothing seemed to help. Nothing except medication. I had been to numerous  doctors and was diagnosed with migraine, tension  and sinus headaches. No matter the diagnosis or the subsequent interventions (I have tried quite a few of them; from different manual therapy techniques working on my trigger points/taut bands at the neck ,to steam inhalation for stubborn sinuses, proper hydration, breathing techniques in a sensory deprived atmosphere, Kinesiology tapes to making dietary changes) the one thing that has provided me relief over the years is, medication. Some of the remedies  have helped me a little but I’d be lying if I said that any of them took my pain away except medication.

As a therapist treating people with headaches I have often found a strong co-relationship between headaches and neck pain. Now for those of us in this profession, this is hardly a breaking news. There is tons of research out there that points out to the fact that a lot of headaches start from the neck and a lot of neck pain symptoms mimic migraine pain. Sure the neck muscles feel stiff and tight and you might find a few trigger points at the upper trapezius, levator scapula, the SCM’s and the other usual suspects. However, the challenge lies in the management of the condition when someone is experiencing an episode of headache.  In my own experience working with patients, when someone walks in my office with a headache, any kind of hands on intervention around the head, neck, TMJ, especially the aggressive kind has yielded me less than favorable outcomes.  I have done this before only to make matters worse and have also been at the receiving end of such treatment interventions. I didn’t like them.

Sticking to the mantra of ‘less is more’ principle as it relates to manual therapy, I have been using a lot of McKenzie treatment principles which has been a game changer for me in managing my own headaches and that of my patients. So now, when I see a patient with headaches, I prefer a more ‘hands off’ approach as I do not want to trigger an already sensitized neuro-muscular system. So instead I do a quick postural assessment and I try to correct what I think are the more common dysfunctional patterns that I have come across in people with cervicogenic headaches. The common pattern resembles our typical upper crossed syndrome pattern of –

  1. Forward head position with increased cervical lordosis and resultant upper cervical spine extension causing compression of important cervical nerve roots and sub cranial dysfunction.
  2. Increased kyphosis of the thoracic spine.

How do I correct them? If the headaches are sever and the patient is highly sensitized, I have them lay down in a supine position with a small pillow under the upper/middle back with no pillows under the head making sure that the chin is in a retracted (tucked in) position.  Now, some of your patients might tolerate this position better than others. For the geriatric population or with people with highly kyphotic, stiff thoracic spine you might want to consider giving them a few pillows under the knees to reduce the tension on the lower back by causing an anterior pelvic tilt (remember, making a person as comfortable as possible helps). Ask them to lay in this position for about 5 minutes. If their symptoms of headache/neck pain seem to subside with this position, chances are that their migraine headaches might be arising due to faulty posture and neck pain. I could and often do classic chin tucks to see if the symptoms subside but again in my experience in the trenches, the less I do, the better. Hence, I regress the chin tucks in a non weight-bearing position and leave them be for a few minutes in a nice quite room. Having your patients do diaphragmatic breathing in this position may be the icing on the cake.

 

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Needless to say, this is not the only method to manage headaches (not to forget there are different types of headaches). However, it is one of the easier ways to do it, very well tolerated by patients compared to the traditional ‘hands-on’ during an acute episode and also a good diagnostic tool to see if the patient will respond well to repeated loading strategies. As the symptoms subside, I’ll start doing some soft tissue work (always gentle, of course) on the hypertonic upper traps, levators and upper cervical muscles etc and follow with exercises. More on that on my subsequent blog on this topic.

I would love to hear your feedback and some of the strategies you use to treat this condition.

 

As always, pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)