Migraine | Diagnosis & Treatment | All a physio needs to know

Physiotherapy for Migraines | Assessment & Treatment
Introduction & Epidemiology
The word “migraine is derived from the Greek word “hemikrania,” which was eventually translated into Latin as “hemigranea,” which was eventually translated to “migraine” in French. They are characterized by throbbing pain on one side of the head, a migraine is a moderate to severe headache.
Migraine attacks are intricate brain processes that frequently last from several hours to several days. Without an aura, migraines are most frequently encountered (75 percent of cases).
Additionally, a lot of people experience symptoms like feeling or being unwell, as well as increased sensitivity to light or sound.
Around 1 in 5 women and 1 in 15 men suffer from migraines, making it a widespread medical disease. Early adulthood is typically when they start.
Epidemiology
Stovner et al. (2007) found a lifetime prevalence of 14% for migraine. Migraines are about 3 times more prevalent in women compared to men. First episodes often start during puberty and prevalence increases until the ages of 35 to 39 before it decreases, especially after menopause (Lipton et al. 2007). In addition, it is ranked second in terms of the number of years people spend living with a handicap, after back pain.
When looking at the current prevalence of different forms of headaches, TTH is the most prevalent form in the adult population worldwide with a mean prevalence of 42%, followed by migraine with 11% (Stovner et al. (2007). The following graph shows the current prevalence of different forms of headaches in different age categories (Stovner et al. (2007):
The following figure shows the prevalence of headaches on different continents around the world:
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Clinical Picture & Examination
The ICD-H III defines the following criteria to diagnose a migraine headache without aura:
Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia.
Diagnostic criteria:
A. At least five attacks1 fulfilling criteria B-D
B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)2;3
C. Headache has at least two of the following four characteristics:
1. unilateral location:
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
2. During headache at least one of the following:
-
- nausea and/or vomiting
- photophobia and phonophobia
Migraines with aura are defined as follows:
Recurrent attacks, lasting minutes, of unilateral fully-reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.
Diagnostic criteria:
A. At least two attacks fulfilling criteria B and CB. One or more of the following fully reversible aura symptoms:
- visual
- sensory
- speech and/or language
- motor
- brainstem
- retinal
C. At least three of the following six characteristics:
- at least one aura symptom spreads gradually over ≥5 minutes
- two or more aura symptoms occur in succession
- each individual aura symptom lasts 5-60 minutes1
- at least one aura symptom is unilateral2
- at least one aura symptom is positive3
- the aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another ICHD-3 diagnosis.
Examination
In comparison with healthy controls, migraineurs differ on provocation testing as well as neck endurance testing.
In comparison, Szikszay et al. (2019) conducted a systematic review and meta-analysis on the differences between MSK impairments in migraineurs and healthy people.
They recommend including testing for limited cervical ROM including the flexion-rotation test, forward head position, and pressure pain thresholds.
The goal of provocation tests is to recreate the patient’s familiar pain. This way, you are able to confirm the location of nociception in the cervical structures, possibly leading to referred pain to the head. While provocative testing for CGH can be done with the techniques shown in the following tab, the phenomenon of referred pain to the head for tension-type headaches and migraine can be provoked with the Watson test:
Although no clear cut-off values are given, the performance time can give an indication about neck flexor endurance:
Upper cervical range of motion in the direction of rotation can be reliably and accurately assessed with the Flexion-Rotation Test (Hall et al. 2010a, Ogince et al. 2007, Hall et al 2010b). This test – if positive – can give you an indication of limited rotation on segments C1/C2. In turn, hypomobility on C0/C1 or C2/C3 can lead to this limitation in rotation on C1/C2.So in case of a positive test, we still need to perform intervertebral motion assessment of all upper cervical segments in order to find the dysfunctional segment.
100% Free Headache Home Exercise Program
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Treatment
In the review and meta-analysis by Luedtke et al. (2016), it was found that sub-analyses of the different physiotherapy interventions showed that aerobic exercise and a combination of physical and psychological interventions were effective for the reduction of migraine attack duration; however, no trials were available that used either manual therapy, trigger point therapy, or strength training. In their systematic review and meta-analysis, Lemmens et al. (2019) confirm that aerobic exercise seems to be able to reduce migraine frequency with a mean reduction of 0.6 ± 0.3 migraine days/month. Krøll et al. (2018) investigated the effects of aerobic exercise in migraineurs with concomitant TTH and neck pain and found that exercise reduced migraine frequency, pain intensity, and duration pre and post-intervention. However, compared to the control group, the results did not reach significance.
In the case that neck endurance is reduced, you might want to try the following exercise program:
References
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What customers have to say about this online course
- Max Dienemann09/10/23Headache Treatment in Clinical Practice TOP
Great course! Everything is covered from diagnosis to treatment (-options) including the latest evidence backing everything up. The practical/skills videos on are also perfectly explained, therefore hands on skills and exercises can be easily implemented in daily practice.Danitsja Wendt11/09/23Headache Treatment in Clinical Practice UITGEBREIDE HOOFDPIJNCURSUS
Veel informatie over de drie meest voorkomende hoofdpijnsoorten. Eerst uitgebreid theoretische achtergrond.
Daarna ook veel aandacht voor onderzoeken en behandelingen, verduidelijkt met filmpjes.
Fijn dat deze informatie ten alle tijden teruggekeken kan worden voor een opfrisser.
De cursus zelf is vertaald in het Nederlands, maar de vele wetenschappelijke artikelen zijn dat helaas niet.
Hierdoor ging bij mij wel erg veel tijd zitten in het doornemen daarvan.
Comment Physiotutors: All scientific literature is in English. That is a reality that we cannot change.Willem Nijssen31/07/23Headache Treatment in Clinical Practice GOOD QUALITY COURSE WITH UP-TO-DATE LITERATURE
The course is well structured and with up-to-date literature. It provides enough practical tips. There’s definitely a lot to learn about this subject! - Jesse de Louw11/07/23Headache Treatment in Clinical Practice GOOD COURSE
Good EBP study, with a nice variety of information. Sometimes a little bit hard to follow the information given in another language than my own. (Comment Physiotutors: This customer probably did not see the option to switch to Dutch)Hamad Alkahtani16/06/23Headache Treatment in Clinical Practice Very Interesting info and practical knowledgeM.A.G. Kuipers15/06/23Headache Treatment in Clinical Practice INFORMATIEVE CURSUS MBT HOOFDPIJN
Goede cursus, helaas niet in Nederlands en helaas zijn ook niet alle artikelen makkelijk te verkrijgen
duidelijke filmpjes met goede technieken mbt onderzoek en behandeling
Opmerking Physiotutors: De gehele cursus is wel in het Nederlands verkrijgbaar. - Lennart Kroes17/04/23Headache Treatment in Clinical Practice A PERFECT COURSE TO UPDATE YOUR KNOWLEDGE ABOUT HEADACHE
Evidence-based, easy to follow. Perfect!Erik Swarts09/03/23Headache Treatment in Clinical Practice GREAT COURSE!
First time doing a Physiotutors course. great way to learn on a high level of evidence. You can watch and rewatch everything for as long as you want before you take the exam.Daniel Klimsa31/01/23Headache Treatment in Clinical Practice GREAT COURSE!
Well-structured course with lots of evidence-based material.
Theory is well explained and you get a lot of additional reading material.
I would like to see improved quality of the explanations in the video portion of the course. - Barbara Fasol18/01/23Headache Treatment in Clinical Practice A LOT OF INFORMATION!
a lot of good informations, articles.
A really good help to improve your comprehension and your practice
The only downside on this course was for some videos in the practice section, the sound wasn’t working (Comment from Physiotutors: This is intended like this). However, the videos were fairly straight forward without the sound so it was fine to understand the content, so it wasn’t much of an issue to have no sound.
For some section, it didn’t include the latest research but it’s difficult to constantly update the content of a course when new research is published everyday.
One very good point was the fact that the teacher critics some of the studies that were published so you feel that it’s not just reading the conclusion.Alice Dehout28/12/22Headache Treatment in Clinical Practice GOOD INSIGHT ON HEADACHE TREATMENT
First time doing a course with physiotutors.
I would say the content is very useful, interesting and up to date.
The only downside on this course was for some videos in the practice section, the sound wasn’t working (Comment from Physiotutors: This is intended like this). However, the videos were fairly straight forward without the sound so it was fine to understand the content, so it wasn’t much of an issue to have no sound.
For some section, it didn’t include the latest research but it’s difficult to constantly update the content of a course when new research is published everyday.
One very good point was the fact that the teacher critics some of the studies that were published so you feel that it’s not just reading the conclusion.Mathias28/11/22Headache Treatment in Clinical Practice QUALITY GUARANTEED
First time using Physiotutors; a very user friendly way of learning. An in depth theoretic background to start off with, before continuing to a more practical approach. After every chapter, you’re invited to do a little quiz and thus test yourself. Highly applicable course for your practice. - Anthony02/09/22GREAT LEARNING EXPERIENCE INFORMATIEVE CURSUS
First time doing a full online formation on a subject and it was amazing, great way to move through the different topics.
The assessment and quizz keeps you accountable and you have a great, practical tool that you can apply directly into your practice like next day in.
Highly recommendedIngeborg Dols-de Jonge16/02/22Headache Treatment in Clinical Practice INFORMATIEVE CURSUS
Leuke en interessante hoofdpijn cursus waarbij gebruik gemaakt wordt van up to date wetenschappelijke onderzoeken. Er wordt een mooie afwisseling gemaakt tussen theorie en praktijk. Na deze cursus kun je goed onderscheid maken tussen verschillende soorten hoofdpijn en weet je wat de beste behandelmethode is.Svein Inge31/01/22Headache Treatment in Clinical Practice QUALITY COURSE
I highly recommend this course. You will get many tips of articles who are relevant for diagnostic and treatment of the most common headaches and migraine. Castien is also a great teacher, and explain the stuff in a good way. He has also informative videos. - Azad Khan04/01/22Headache Treatment in Clinical Practice AN EXPERTS GUIDE THROUGH THE HEADACHE LANDSCAPE!
No better tutor than René Castien to introduce us to the fascinating field of the treatment rationale and possibilities for physio- and manual therapists. Uptodate, for so far as possible in this fast moving field, practical and with a good deal of treatment options that are both evidence based and with a good deal of clinical expertise. I thoroughly enjoyed the course and was pleasantly surprised by the clear and methodogical presentation of the material. I can highly recommend this course to any clinician engaged with or interested in the treatment of patients with headache. A no nonsense, applicable and practical course!Elisabetta12/12/21Headache Treatment in Clinical Practice DETAILED AND VERY INFORMATIVE
This course is ideal to expand one’s knowledge on headaches and how to effectively treat them.
The instructor is extremely knowledgeable and provides very practical information, easily applicable in the clinic.
I would highly recommend taking this course to anyone interested in becoming an expert at treating headaches.Dylan08/12/21Headache Treatment in Clinical Practice GREAT COURSE
Good didactic qualities of the teacher with clearly noticeable theoretical knowledge